Synopsis
Distinguish fluid, liver and spleen enlargement at the bedside, identify decompensated cirrhosis, spontaneous bacterial peritonitis, malignancy and vascular disease promptly, and use ultrasound plus diagnostic paracentesis to establish mechanism.
- New ascites is a diagnosis to explain, not merely a sign to diurese: confirm it with ultrasound and sample it unless a clear contraindication or specialist reason exists.
- Any patient with cirrhosis and ascites admitted acutely should have prompt diagnostic paracentesis, including when abdominal pain or fever is absent.
- Ascitic neutrophils at or above 250 cells/mm³ support spontaneous bacterial peritonitis and should trigger immediate treatment under the local pathway.
Key red flags
Fever, abdominal pain, encephalopathy, hypotension, ileus, acute kidney injury or otherwise unexplained decompensation can be the presentation. A painless abdomen is common enough that routine admission taps matter.
Investigation priorities
Confirm ascites, measure liver and spleen, assess contour and focal lesions, and evaluate portal and hepatic venous flow while identifying a safe paracentesis window.
Management branches
New ascites, or cirrhosis with ascites during an acute hospital admission.
- Assess ABCDE, renal function, encephalopathy, bleeding and sepsis; use ultrasound to confirm fluid and select a safe site.
- Perform prompt diagnostic paracentesis and send cell count, bedside cultures, albumin and protein, adding cytology or other tests only where indicated.
Key medicines
SpironolactoneA common specialist starting regimen for a first presentation of moderate cirrhotic ascites is 100 mg orally daily, titrated cautiously up to 400 mg daily; verify current BNF, renal function and local hepatology policy.
FurosemideOften 40 mg orally daily when combination therapy is appropriate, titrated with spironolactone up to a specialist maximum such as 160 mg daily; use current BNF and local protocol.