Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 8, 2016; 8(28): 1182-1193
Published online Oct 8, 2016. doi: 10.4254/wjh.v8.i28.1182
Management of refractory ascites in cirrhosis: Are we out of date?
Alagappan Annamalai, Lauren Wisdom, Megan Herada, Mazen Noureddin, Walid Ayoub, Vinay Sundaram, Andrew Klein, Nicholas Nissen
Alagappan Annamalai, Lauren Wisdom, Megan Herada, Mazen Noureddin, Walid Ayoub, Vinay Sundaram, Andrew Klein, Nicholas Nissen, Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, CA 90048, United States
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Alagappan Annamalai, Comprehensive Transplant Center, Cedars Sinai Medical Center, 8900 Beverly Blvd, 2nd fl. Suite 262, Los Angeles, CA 90048, United States.
Telephone: +1-310-4232975
Received: March 11, 2016
Peer-review started: March 14, 2016
First decision: April 20, 2016
Revised: July 22, 2016
Accepted: August 6, 2016
Article in press: August 8, 2016
Published online: October 8, 2016

Cirrhosis is a major cause of morbidity and mortality worldwide with liver transplantations as it only possible cure. In the face of a significant organ shortage many patients die waiting. A major complication of cirrhosis is the development of portal hypertension and ascites. The management of ascites has barely evolved over the last hundred years and includes only a few milestones in our treatment approach, but has overall significantly improved patient morbidity and survival. Our mainstay to ascites management includes changes in diet, diuretics, shunt procedures, and large volume paracentesis. The understanding of the pathophysiology of cirrhosis and portal hypertension has significantly improved in the last couple of decades but the changes in ascites management have not seemed to mirror this newer knowledge. We herein review the history of ascites management and discuss some its current limitations.

Keywords: Portal hypertension, Cirrhosis, Ascites, Transhepatic portosystemic shunts, Paracentesis

Core tip: Few randomized control studies have been performed in the management of refractory ascites, of which all were performed either in the pre-model for end-stage liver disease (MELD) era or done in patients with low MELD scores. As such, most of the management guidelines have significant limitations in its utility for patients admitted to the hospital with significant hemodynamic dysfunction and other complications of cirrhosis. Our objective is to review the origins of our current management of refractory ascites and its limitations.