Ascites: What to Do When Oral Diuretic Therapy Has Not Resolved It
Clinical Scenario
This protocol applies when ascites has persisted despite an optimised oral diuretic regimen — specifically where combination diuretic therapy has been titrated progressively without achieving resolution of ascites.
Prior Line — Failure Condition
The preceding treatment involved oral frusemide in combination with spironolactone, both titrated upward with careful biochemical and clinical monitoring. Escalation to this protocol is triggered by failure to achieve resolution of ascites on that regimen.
Next-Line Approach
The next step is a procedural intervention — therapeutic paracentesis — combined with plasma volume expansion. The specific approach and choice of volume-expansion agent differ based on the amount of fluid drained. The complete clinical algorithm is in the structured protocol.
References
DOI: 10.1136/gut.2006.099580
- Therapeutic paracentesis is the firstline treatment for patients with large or refractory ascites.
- Paracentesis of <5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander (150–200 ml of gelofusine or haemaccel), and does not require volume expansion with albumin.
- Large volume paracentesis should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/litre of ascites removed (that is, <100 ml of 20% albumin/3 l ascites).
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