This is an official Northern Trust policy and should not be edited
in any way
Ascites Management Guidelines for
Liver Cirrhosis
Reference Number:
NHSCT/13/658
Target audience:
These guidelines are relevant to medical and nursing staff working within
Emergency Departments, Gastroenterology and Medical Admission Wards
throughout the Trust.
Sources of advice in relation to this document:
Dr Gerard Rafferty, Consultant
Replaces (if appropriate): N/A
Type of Document:
Directorate Specific
Approved by:
Policy, Standards and Guidelines Committee
Date Approved:
4 March 2013
Date Issued by Policy Unit:
19 March 2013
NHSCT Mission Statement
To provide for all the quality of services we would expect for our families
and ourselves
Ascites Management Guidelines for
Liver Cirrhosis
Authors: G. Jacob, G. Rafferty, P. Lynch, C. Rodgers, S. Ali, T. McLean.
Produced: April 2011
Revised: February 2013
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Ascites Management Guidelines for Liver Cirrhosis
Introduction
Ascites management guidelines for liver cirrhosis have been revised to ensure
best practice guidance is followed with regard to patient diagnosis using a
diagnostic tap and subsequent treatment/patient management.
Aim
To develop best practice guidance to improve ascites management in patients
with liver cirrhosis.
Target Audience
These guidelines are relevant to medical and nursing staff working within
Emergency Departments, Gastroenterology and Medical Admission Wards
throughout the Trust.
Dietetic staff working within the acute hospital setting also need to be aware of
their role in providing dietary advice.
Responsibilities
It is the responsibility of all relevant staff (medical and nursing) to familiarise
themselves with these guidelines and utilise them appropriately within their scope
of practice. Dietitians are responsible for providing dietary advice, as appropriate
Policy Statement/Actions
Diagnostic Tap
Diagnostic tap should be performed in all:
1. New onset Type 2 (moderate) or 3 (gross) ascites
2. Hospitalised patients for worsening ascites
3. Complications of cirrhosis such as encephalopathy, hepato-renal
syndrome, variceal bleeding, sepsis.
Diagnostic tap should be performed in above patients at time of decision to admit
using aseptic non-touch technique (ANTT). This should be performed as soon as
possible – ideally by medical admission team. Ultrasound (USS) marking not
required. 20ml ascitic fluid aspirated using green needle and syringe and fluid is
sent for:
a) biochemistry (albumin - patients with cirrhosis will have transudate with a
SAAG (Serum Ascites Albumin Gradient) of >11 g/L))
b) cytology
c) haematology (WBC count) – urgent and chase result
d) organisms (blood culture bottles)
e) amylase if there is suspicion of pancreatic disease.
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Large volume paracentesis (LVP)
LVP does not require Ultrasound (USS) marking. Large volume ascites not
responding to medical therapy or causing respiratory distress or discomfort
should be managed by performing total abdominal paracentesis as follows:
1. Have patient empty bladder.
2. Position the patient in the bed with the head elevated 45-90 degrees. This
allows fluid to accumulate in lower abdomen.
3. Put on sterile gloves.
4. Sterilize the site with iodine and then alcohol.
5. Place sterile draping towels
6. Inject Lignocaine 2% on to and including the peritoneum
7. A small nick is performed using a #11 scalpel
8. Introduce the catheter assembly of a ‘Bonnano’ catheter through the
abdominal wall by using short thrusts at first obliquely up to peritoneum
and perpendicularly to penetrate the peritoneum until resistance
disappears. If you are in position, fluid should run free after removing the
vent plug.
9. Disengage the needle from the catheter hub. Holding the needle to use it
as a guide, advance catheter until the suture disc is flat against the skin.
10. Connect the adaptor clamp as directed and secure it by tape to the
abdominal wall
11. Finally, connect the drainage bag to the catheter, emptying it as
necessary.
Observations are recorded every 15 minutes. If there is any evidence of
hypotension, the drainage should immediately be stopped by clamping.
Up to 10L can be safely drained in one attempt, but up to 22L have been
reported to have been drained.
Remove the drain after 6 hours or earlier if the fluid has stopped draining to
prevent secondary infection. Seal the site with pressure bandage. Patient should
lie on the opposite side if there is leakage of fluid and/or a purse string suture
applied if necessary.
Give 100 ml 20% Human Albumin Solution (HAS) for every 2-3L of ascitic
fluid removed. This should ideally be started simultaneously at the
beginning of paracentesis to prevent hypotension and hepatorenal
syndrome.
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Spontaneous Bacterial Peritonitis (SBP)
An ascitic neutrophil count of >250 cells/mm3 is suggestive of SBP and broad
spectrum antibiotics should be administered e.g. Tazocin. Antibiotic therapy
should be commenced if there is clinical suspicion of infection even if neutrophil
count is <250 cells/mm3. If raised creatinine or rising creatinine then consider IV
Human Albumin Solution (Day 1: 1.5g albumin per kg and Day 3: 1g albumin per
kg.)
Medical Rx
1.Restrict sodium intake to 6g/day (Need dietitian to explain to patient)
2.Start Spironolactone 100mg/day.
3.If no response after 3 days, increase dose of Spironolactone stepwise to a daily
dose of 400mg/day and add in Furosemide 40-160mg/day under
Consultant/Associate Specialist supervision (monitor U&E daily).
4.Serum sodium
126-135mmol/L: Do not restrict fluids and continue diuretics
121-125mmol/L:
a. with normal creatinine: BSG guidelines suggest stopping diuretics
b. with high creatinine:
stop diuretics and give volume expansion
<120 – Stop diuretics and give colloids/0.9%
sodium chloride (normal saline)
5. Chronic liver disease patients have high nutritional requirements (25-45 kcal
per kg depending on compensated/decompensated and at least 1.2-2g protein
per kg. Early assessment and intervention is key to improving outcomes in this
group. MUST is unhelpful due to inaccuracy of weight in this patient group.
Protein energy malnutrition is common.
Other options:
•
•
Transjugular intrahepatic portosystemic shunt (TIPS)
Liver transplant
Equality, Human Rights and DDA
This policy has been drawn up and reviewed in the light of Section 75 of the
Northern Ireland Act (1998) which requires the Trust to have due regard to the
need to promote equality of opportunity. It has been screened to identify any
adverse impact on the 9 equality categories and no significant differential impacts
were identified, therefore, an Equality Impact Assessment is not required.
Alternative Formats
This document can be made available on request on disc, larger font, Braille,
audio-cassette and in other minority languages to meet the needs of those who
are not fluent in English.
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Sources of Advice in relation to this document
The Policy Author, responsible Assistant Director or Director as detailed on the
policy title page should be contacted with regard to any queries on the content of
this policy.
References:
1. EASL clinical practice guidelines on the management of ascites, spontaneous
bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of
Hepatology 2010 vol. 53 j 397–417.
2. BSG Guidelines on the management of ascites in cirrhosis. Gut 2006; 55; 112.
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