Management of intractable ascites in cirrhosis: a review article

Abstract

Intractable ascites (IA) also referred to as refractory ascites, is a severe complication of cirrhosis marked by resistance to standard diuretic therapy. Its occurrence reflects advanced portal hypertension and is associated with poor prognosis. This literature review summarizes current evidence and management strategies for IA in cirrhotic patients. Sodium restriction remains a core component of management, even in diuretic-resistant cases. Large-volume paracentesis (LVP) with albumin infusion is considered first-line therapy, though it carries the risk of post-paracentesis circulatory dysfunction. Long-term albumin administration shows potential benefits but requires further confirmation. In selected patients, transjugular intrahepatic portosystemic shunt (TIPS) offers sustained ascites control. For non-TIPS candidates, the alfapump system provides continuous ascites drainage, improving appetite, mobility, and quality of life, though long-term antibiotic prophylaxis is required to prevent device-related infection. Liver transplantation remains the only curative option, and combined liver–kidney transplantation should be considered in patients with concurrent chronic kidney disease. Management of IA in cirrhosis requires a multidisciplinary approach. While LVP and TIPS remain the therapeutic mainstays, emerging strategies such as long-term albumin therapy and alfapump devices are promising. Given its poor prognosis, timely evaluation for liver transplantation is crucial.