Posted by e-Medical PPT Thursday, October 7, 2010
Refractory ascites: Is the ascites that cannot be mobilized or the early recurrence of which cannot be satisfactorily prevented by medical therapy.It includes the following two subtypes.
Diuretic-resistant ascites: is refractory ascites due to a lack of response to dietary sodium restriction and intensive diuretic therapy.
Diuretic-intractable ascites: is refractory ascites due to the development of diuretic-induced complications that preclude the use of an effective diuretic dosage.

  1. Treatment duration: Patients must be on intensive diuretic treatment for at least 1 week.
  2. Lack of response: Mean loss of weight less than 200g/day during the last 4 days of intensive diuretic therapy and urinary sodium excretion lower than 50mEq/day.
  3. Dietary sodium restriction: A 50-mEq sodium diet.
  4. Intensive diuretic treatment: Spironolactone 400mg/day plus furosemide 160mg/day (bumetanide 4mg/day or equivalent doses of loop diuretics).
  5. Early ascites recurrence: Reappearance of grade 2 (moderate) to 3 (massive or tense) ascites within 4 weeks of initial mobilization.
  6. Diuretic induced complications:
  • Hepatic encephalopathy- In the absence of other precipitating factors.
  • Renal failure-Increased serum creatinine to a value of 2 gm/dl in patients with ascites responding to diuretics.
  • Hyponatremia- Decreased serum sodium to a value lower than 125 mEq/L.
  • Hypo or hyperkalemia-Decreased serum potassium to a value lower than 3 mEq /L or an increase to a value greater than 6 mEq /L .

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