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Textbook/Palliative and end-of-life care/Ascites and oedema/Rapid
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Ascites and oedema

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Infected, tense or organ-threatening fluid

Ascites with sepsis, new encephalopathy, gastrointestinal bleeding, shock or kidney injury may represent spontaneous bacterial peritonitis or decompensated cirrhosis. Rapidly increasing abdominal pressure, severe dyspnoea, anuria, unilateral swollen leg or spreading skin infection also needs urgent assessment.

Action: Use ABCDE assessment, obtain observations, glucose, intravenous access and urgent bloods, and perform prompt diagnostic paracentesis before antibiotics when this causes no harmful delay. Treat sepsis and decompensation under the local pathway, assess venous thrombosis or cellulitis, and use monitored drainage when pressure itself is compromising breathing or comfort.

Synopsis

Assess fluid by mechanism, recognise emergencies, relieve pressure safely and choose drainage, diuretics, compression or skin care according to cause, monitoring burden and goals.

  • Ascites is free peritoneal fluid; peripheral oedema is interstitial fluid. Both are signs with malignant, portal-hypertensive, cardiac, renal, venous, lymphatic, drug and low-albumin causes.
  • First-line assessment establishes onset, breathlessness, pain, fever, urine output, weight trend, medicines, liver and cardiac signs, unilateral versus bilateral swelling and the desired outcome.
  • Urgently assess fever with abdominal pain, shock, new encephalopathy, oliguria, rapidly worsening dyspnoea, unilateral painful swelling or threatened skin.

Key red flags

Fever, abdominal tenderness, new confusion, hypotension or rising creatinine with ascites suggests infected fluid even when pain is mild.

Spontaneous bacterial peritonitis

Abdominal pain, fever, hypotension, encephalopathy or renal decline in cirrhotic ascites requires urgent diagnostic tap and antibiotics.

Investigation priorities

01
First-line bedside assessmentFirst stepFirst line

Define observations, perfusion, weight trend, girth, jugular pressure, lungs, abdominal tension, pitting distribution, skin and unilateral features.

Management branches

Immediate assessmentExclude infection and organ compromise

Ascites or oedema is new, rapidly worse, painful, febrile or associated with breathlessness, confusion or oliguria.

  1. Assess ABCDE, sepsis, respiratory effect, perfusion, urine output, unilateral leg signs and skin; clarify escalation wishes without delaying immediate comfort.
  2. Obtain urgent bloods and ultrasound and perform diagnostic paracentesis promptly in cirrhosis or suspected peritonitis when safe; investigate DVT or cardiac failure as indicated.

Key medicines

Spironolactone for portal-hypertensive ascitesA common cirrhosis regimen starts at 100 mg orally daily and titrates at intervals toward 400 mg if required; frail palliative patients often need a lower individual start under local hepatology guidance.
Furosemide with spironolactoneFor recurrent or severe cirrhotic ascites, a common paired start is furosemide 40 mg with spironolactone 100 mg orally daily, titrated in the same 40:100 ratio under protocol.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom