Cirrhotic ascites: pathogenesis and management.

The pathogenesis of ascites can be divided into (1) factors that favor efflux of fluid from the vascular into the peritoneal space (sinusoidal hypertension, hypoalbuminemia), (2) factors that favor accumulation of fluid in the peritoneal cavity (thoracic duct insufficiency), and (3) factors responsible for repletion of the intravascular volume, and thereby continuous formation of ascites (sodium and water retention). Ascites is perhaps the one complication of cirrhosis with the lowest therapeutic priority. Current therapy of ascites is mainly directed at attaining a negative sodium balance (sodium restriction, diuretics) or at removing intraperitoneal fluid and returning it or its components back to the systemic circulation (large volume paracentesis accompanied by plasma volume expanders, peritoneovenous shunt, ascites "recycling" procedures). Future studies of ascites should investigate the usefulness of peripheral vasoconstrictors and nonsurgical side-to-side portosystemic shunting to relieve sinusoidal hypertension (transjugular intrahepatic portosystemic shunt). More than 90% of patients respond to diuretics and salt restriction. Other therapeutic measures should be directed at the 10% of patients with ascites refractory to diuretics. Prognosis in these patients is poor, and liver transplantation should be contemplated.