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Health condition · Clinically reviewed

Ascites, the SAAG, the diuretic ladder - and when to think TIPS or a drain.

Fluid in the abdomen is a signal, not a diagnosis. A proper workup - starting with a diagnostic tap - turns that signal into a plan.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, BSG, EASL and AASLD sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including SAAG-based workup, TIPS, tunnelled drains and the alfapump.

Key facts

Ascites at a glance.

The essentials, in plain English - what it is, what causes it, and how UK teams work it up in 2026.

  • What it is

    Pathological fluid in the peritoneal cavity - clinically detectable once volumes exceed roughly 1.5 litres.

  • Most common cause

    Cirrhosis accounts for about 75 per cent of cases via portal hypertension and low serum albumin.

  • Malignancy

    Around 10 per cent - peritoneal carcinomatosis from ovarian, colorectal, gastric, pancreatic or mesothelioma primaries.

  • Cardiac and TB

    Roughly 5 per cent from heart failure and 2 per cent from peritoneal tuberculosis - both underdiagnosed.

  • The key test

    Diagnostic paracentesis is mandatory in new-onset ascites - SAAG separates portal from non-portal causes.

  • SBP is dangerous

    Spontaneous bacterial peritonitis (PMN over 250) is a medical emergency with 20 per cent inpatient mortality.

Why this guide matters

Fluid is a symptom - the cause changes everything.

Cirrhotic, malignant, cardiac and tuberculous ascites all look similar in the abdomen but are treated in completely different ways. The three points below shape the rest of the page.

  • Always tap new ascites

    Diagnostic paracentesis is mandatory - the SAAG, cytology and neutrophil count reset the entire management plan.

  • Sodium and diuretics come first

    For cirrhotic ascites, salt restriction with spironolactone and furosemide control most patients before invasive options are needed.

  • Refractory ascites has options

    TIPS, tunnelled drains, the alfapump and transplant assessment are all available - patients should not be left on monthly paracentesis alone.

How the diagnosis is made

From a distended abdomen to a clear cause.

The steps a UK hospital team will follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Clinical assessment

    Distension, shifting dullness, flank fullness and fluid thrill - alongside stigmata of liver disease, cardiac status and cancer history.

  2. 02

    Assessing

    Bedside ultrasound

    Confirms free fluid, guides paracentesis and gives a first look at liver architecture, portal vein and spleen.

  3. 03

    Assessing

    Diagnostic paracentesis

    Cell count and differential, albumin (for SAAG), total protein, culture in blood-culture bottles, cytology, amylase, triglycerides and ADA where indicated.

  4. 04

    Confirming

    Bloods and cardiac markers

    LFTs, INR, urea, creatinine, sodium, albumin and BNP - to classify the cause and stage the underlying disease.

  5. 05

    Confirming

    Cross-sectional imaging

    CT abdomen and pelvis, plus PET-CT where malignancy is suspected, to stage cancer and characterise the peritoneum.

  6. 06

    Confirming

    Endoscopy and echocardiography

    Upper and lower GI endoscopy for varices or cancer; echocardiogram (with hepatic vein Doppler for Budd-Chiari) for cardiac and vascular causes.

  7. 07

    Refining

    Selective advanced tests

    Transjugular liver biopsy with hepatic venous pressure gradient, laparoscopy with peritoneal biopsy for suspected TB or occult malignancy.

Typical timeline: a first presentation to a working diagnosis within days, not weeks.

Symptoms

What ascites actually feels like.

The mix of distension, breathlessness and systemic features - and the signals that mean it is time to escalate to hospital.

  • Abdominal distension

    Progressive swelling, tight waistband, umbilical eversion - often the first thing patients notice.

  • Shifting dullness and fluid thrill

    Classic bedside signs - reliable once around 1.5 litres of fluid is present.

  • Weight gain and reduced appetite

    Rapid weight change with early satiety as fluid displaces the stomach.

  • Breathlessness

    Splinting of the diaphragm and hepatic hydrothorax can cause exertional and positional dyspnoea.

  • Peripheral oedema

    Bilateral leg swelling from hypoalbuminaemia and raised intra-abdominal pressure.

  • Stigmata of liver disease

    Spider naevi, palmar erythema, gynaecomastia, caput medusae and jaundice point to a cirrhotic aetiology.

  • Cachexia and malignant features

    Weight loss with fluid gain, night sweats, pelvic or GI symptoms suggest peritoneal carcinomatosis.

  • Red flag - fever or abdominal pain

    Fever, tenderness or encephalopathy in a patient with ascites should prompt urgent paracentesis for suspected SBP.

Treatment

How ascites is treated in the UK.

Treat the underlying cause first, then a stepped plan - salt, diuretics, paracentesis and, when needed, TIPS, drains or transplant.

  • Treat the underlying cause

    Alcohol abstinence, antivirals for hepatitis, systemic therapy for cancer, guideline-directed heart-failure treatment - the foundation of every plan.

  • Salt and fluid restriction

    Dietary sodium 5 to 6 g per day; fluid restriction is reserved for symptomatic hyponatraemia (sodium under 125).

  • Diuretic ladder

    Spironolactone 100 to 400 mg with furosemide 40 to 160 mg in a 100 to 40 ratio - titrated against weight, sodium and renal function.

  • Large-volume paracentesis

    For tense or diuretic-resistant ascites - with 8 g of intravenous albumin per litre removed to prevent circulatory dysfunction.

  • TIPS

    Transjugular intrahepatic portosystemic shunt for refractory cirrhotic ascites in carefully selected candidates - reduces portal pressure and paracentesis frequency.

  • Antibiotics for SBP

    IV cefotaxime for 5 days with albumin (1.5 g per kg on day 1, 1 g per kg on day 3) - then lifelong norfloxacin or ciprofloxacin as secondary prophylaxis.

  • Malignant ascites drainage

    Repeat paracentesis, tunnelled indwelling peritoneal catheter (PleurX, Aspira) or the alfapump - alongside cancer-directed therapy.

  • Liver transplant assessment

    The definitive treatment for refractory cirrhotic ascites and hepatorenal syndrome - early referral changes outcomes.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your hepatology, oncology or cardiology team knows your history and imaging and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Cirrhosis in over 16s: assessment and management (NG50).

  • British Society of Gastroenterology (BSG). Guidelines on the management of ascites in cirrhosis.

  • EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.

  • AASLD Practice Guidance on the diagnosis, evaluation and management of ascites and hepatorenal syndrome.

Red flags

When ascites needs urgent attention.

Many patients live with ascites for months. These are the situations where waiting is unsafe and a hospital review is needed.

  • Spontaneous bacterial peritonitis

    Fever, abdominal pain, encephalopathy or unexplained deterioration - urgent diagnostic tap and empirical antibiotics save lives.

  • Hepatorenal syndrome

    Rising creatinine with no other cause in a cirrhotic patient - needs terlipressin, albumin and transplant assessment.

  • Tense ascites with respiratory distress

    Splinted diaphragm compromising breathing - large-volume paracentesis with albumin cover.

  • New-onset ascites

    Every first presentation deserves a diagnostic paracentesis - the SAAG and cytology change the whole plan.

  • Bloody or chylous fluid

    Suggests malignancy, tuberculosis or lymphatic disruption - never assume a benign cause.

  • Peritoneal carcinomatosis

    Malignant cytology or omental thickening on CT - triggers oncology, cytoreductive surgery and HIPEC discussion in selected cases.

  • Budd-Chiari syndrome

    Painful ascites with hepatomegaly - hepatic vein Doppler and anticoagulation, urgent hepatology input.

  • Umbilical hernia rupture

    Skin breakdown or leakage over a tense hernia is a surgical emergency in cirrhotic patients.

  • Refractory ascites

    Fluid returning within days of paracentesis despite maximal diuretics - assess for TIPS, alfapump or transplant.

Living with it

A manageable condition, with the right team around you.

Four things that make the biggest difference day to day - a low-salt diet, daily weights, abstinence where relevant, and asking about the next step early.

A quiet reminder

Small habits, kept up, do more than big gestures.

Daily weights and a low-salt kitchen quietly outperform any single admission-cycle intervention.

  1. 01 Diet

    Keep sodium low

    Aim for 5 to 6 g of salt per day - most gains come from avoiding processed foods and table salt, not from bland cooking.

  2. 02 Weigh

    Track your weight daily

    A steady daily weight tells us the diuretics are working; a sudden rise is your earliest warning to seek help.

  3. 03 Alcohol

    Full abstinence when cirrhotic

    Stopping alcohol is the single most important thing in alcohol-related liver disease - support is available and effective.

  4. 04 Escalate

    Ask about TIPS or a drain early

    If paracentesis becomes a monthly event, ask about TIPS, a tunnelled drain or the alfapump - refractory ascites has options.

Frequently asked

Everything we get asked about ascites.

Quick answers on the SAAG, SBP, diuretics, TIPS and drainage options.

  • What is ascites?

    Ascites is a pathological accumulation of fluid inside the peritoneal cavity. In the UK the commonest cause is cirrhosis (around 75 per cent), followed by malignancy (around 10 per cent), heart failure (around 5 per cent) and peritoneal tuberculosis (around 2 per cent). Less common causes include nephrotic syndrome, pancreatitis, chylous ascites and Meigs syndrome.

  • Why is diagnostic paracentesis so important?

    A diagnostic tap is mandatory in every new-onset ascites and in any admission with suspected infection. Cell count and differential detect spontaneous bacterial peritonitis (PMN over 250), the serum-ascites albumin gradient (SAAG) separates portal hypertension from non-portal causes, and cytology, amylase, triglycerides and ADA identify malignancy, pancreatitis, chylous ascites and tuberculosis.

  • What does the SAAG tell us?

    The SAAG is the serum albumin minus the ascitic albumin. A high SAAG (11 g per litre or more) means portal hypertension - cirrhosis, cardiac failure, Budd-Chiari or massive hepatic metastases. A low SAAG (under 11) points to non-portal causes such as peritoneal malignancy, tuberculosis, pancreatic ascites, nephrotic syndrome or serositis.

  • How is cirrhotic ascites treated?

    The mainstays are salt restriction (5 to 6 g per day), a diuretic ladder of spironolactone 100 to 400 mg with furosemide 40 to 160 mg in a 100 to 40 ratio, and large-volume paracentesis with intravenous albumin (8 g per litre removed) for tense or refractory disease. TIPS and liver transplant are considered in refractory ascites.

  • What is spontaneous bacterial peritonitis?

    SBP is infection of ascitic fluid without an intra-abdominal source, diagnosed when the ascitic neutrophil count exceeds 250 per mm3. Treatment is intravenous cefotaxime for 5 days plus albumin (1.5 g per kg on day 1 and 1 g per kg on day 3), followed by lifelong secondary prophylaxis with norfloxacin or ciprofloxacin.

  • How is malignant ascites managed?

    The priority is the underlying cancer - systemic chemotherapy where the disease is responsive. Symptomatic control uses repeat paracentesis, a tunnelled indwelling peritoneal catheter (PleurX or Aspira) or the automated alfapump. In selected peritoneal cancers, cytoreductive surgery with HIPEC can be curative or life-extending.

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