Ascites Management and When to Use Therapeutic Paracentesis, with Carolyn Legaspi, NP

A common complication of cirrhosis indicating the transition from compensated to decompensated cirrhosis, ascites is the pathologic accumulation of fluid within the peritoneal cavity and often presents with abdominal distension requiring management with lifestyle interventions, diuretics, or therapeutic paracentesis.

In a session at the 2024 annual Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) conference in National Harbor, Maryland, Carolyn Legaspi, NP, a nurse practitioner at Cedars-Sinai, reviewed how to manage patients with ascites using different first-, second-, and third-line treatment options.

Although cirrhosis is the most common cause of ascites, Legaspi described how providers from different specialties will refer patients with ascites to determine if it is derived from a liver process or another non-liver-related process, such as cancer or heart failure. Its presentation varies, rapidly accumulating over the course of a few days in some patients while others see it develop more gradually over weeks or months.

“Usually we do initial diagnostic paracentesis to kind of run that fluid, and then, if the patient is ongoing accumulating fluid, we'll do a therapeutic paracentesis to remove as much fluid as they may need to be comfortable,” Legaspi explained, citing the diagnostic and therapeutic uses of paracentesis in these patients.

However, she noted paracentesis typically serves as a third-line treatment, with the first-line treatment being lifestyle modification with limited dietary sodium intake and the second-line treatment being diuretics.

“I like to counsel my patients on not really eating a lot of processed foods and preparing as much food at home with fresh fruits, fresh ingredients, and fresh vegetables, as well as just being aware that it's not just salt, but other condiments that are high in sodium that could be causing the fluid accumulation,” Legaspi said, describing how she turns to second-line treatment with diuretics if symptoms persist with dietary intervention. “At that point, if we've already maxed out on our diuretics, then we would have to turn to our third-line treatment, which would be paracentesis.”

If symptoms persist and patients require frequent therapeutic paracentesis, Legaspi noted a transjugular intrahepatic portosystemic shunt (TIPS) procedure may eventually be necessary, or in more extreme cases, a liver transplant.

References

1. ^{Chiejina M, Kudaravalli P, Samant H. Ascites. StatPearls. August 8, 2023. Accessed September 16, 2024. https://www.ncbi.nlm.nih.gov/books/NBK470482/}