Treatment of Liver Cirrhosis in Refractory Ascites When Medical Therapy Fails to Control Fluid
Refractory ascites in liver cirrhosis defines a distinct and clinically demanding situation in which fluid accumulation either cannot be mobilised, or recurs early and cannot be satisfactorily prevented, despite medical therapy.
Clinical scenario
This protocol addresses patients with liver cirrhosis whose ascites cannot be mobilised or whose ascites recurs early and cannot be satisfactorily prevented by medical therapy alone — the defining criteria for refractory ascites.
Approach — partial overview (full regimen in protocol)
Management centres on evaluation for an intrahepatic portosystemic shunt-based procedure, with ongoing medical measures as part of the broader plan. The complete, sequenced regimen — including patient selection criteria, procedural specifics, and post-procedural management — is contained in the full protocol.
References
DOI: 10.1016/j.jhep.2018.03.024
- Repeated LVP plus albumin (8 g/L of ascites removed) are recommended as first line treatment for refractory ascites (I;1).
- Patients with refractory or recurrent ascites (I;1), or those for whom paracentesis is ineffective (e.g. due to the presence of loculated ascites) should be evaluated for TIPS insertion (III;1).
- TIPS insertion is recommended in patients with recurrent ascites (I;1) as it improves survival (I;1) and in patients with refractory ascites as it improve the control of ascites (I;1).
- The use of small-diameter PTFE-covered stents in patients is recommended to reduce the risk of TIPS dysfunction and hepatic encephalopathy with a high risk of hepatic encephalopathy is recommended (I;1).
- Diuretics and salt restriction should be continued after TIPS insertion up to the resolution of ascites (II-2;1), as well as close clinical follow-up (III,1).
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