Top tips:

  1. Perform a diagnostic paracentesis in:
    • Any patient with symptoms or signs of infection, renal dysfunction or encephalopathy.
    • All patients at presentation to ER, even if asymptomatic.
  2. The mainstay of therapy for ascites are sodium restriction and diuretics. spironolactone and furosemide are often given in combination in a ratio of 50 mg (spironolactone) to 20 mg (furosemide).  In cases of mild ascites, spironolactone monotherapy may be enough.
  3. Large volume paracentesis (≥ 5 L drained) is required for tense or refractory ascites. Give IV albumin (100 cc of 25% albumin (25 grams) for every 3 L ascites removed). With renal insufficiency or hypotension, be more cautious with the amount of fluid that is drained off.
  4. Patients with ascites may be candidates for a Transjugular intrahepatic portosystemic shunt (TIPS) or for liver transplantation.
  5. Non-selective beta blockers (NSBB’s) and other blood pressure lowering medications may need to be adjusted in patients with ascites

Order panels for Ascites & Paracentesis:

For adults with cirrhosis admitted with Ascites.
Ascites Hepatic Hydrothorax, Edema in Cirrhosis Order Panel

For adult inpatient with cirrhosis requiring paracentesis.
Inpatient Cirrhosis Paracentesis Order Panel

For adults outpatients with cirrhosis requiring paracentesis.
Outpatient Cirrhosis Paracentesis Order Panel

General Cirrhosis Admission and Discharge Order Sets

*Add specific panels to general admission orders as appropriate*

For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders

For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders

Dr. Tandon cartoon 1
Carbonneau Cartoon
Dr. Abraldes cartoon-needs white hair

Check out the bottom of the page for short videos from Dr. Tandon, Michelle Carbonneau and Dr. Abraldes!


General Management

Specific Management

Serum-ascites albumin gradient

Introducing Dr. Abraldes, Dr. Tandon and Michelle Carbonneau

Video 1 – The top general tips that may be useful for you to know about this page as a family physician

Video 2 - Coming Soon - Practical tips for carrying out large volume paracentesis safely, and what to send the fluid for!

Coming soon!

Video 3 - Transjugular intrahepatic portosystemic shunt (TIPS) for a patient with cirrhosis and ascites or hydrothorax – indications and cautions.

Video 4 – Coming Soon - Indwelling peritoneal catheters for a patient with ascites – indications and cautions.

Coming soon!

Patient materials:

You can direct patients to the following:



Lab tests



Breathing trouble

Portal hypertension

 Downloadable Content:

You can download these to print or view offline:


This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors: Dr. Marilyn Zeman, Dr. Guadalupe Garcia-Tsao, Dr. Vijey Selvarajah, Dr. Brian Buchanan, Dr. Puneeta Tandon


  1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
  2. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis. Hepatology 2013 Apr;57(4):1651-3 PMID 23463403

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