Cause:Multiple etiologies result in end-stage hepatic failure, which has four major complications: ascites, hemorrhage, renal failure, and encephalopathy
Pathophys:Ascites underfill theory is that postsinusoidal block raises portal vein pressure, which causes capsular weeping, which causes decreased blood volume and increased aldosterone and ADH, which causes more extracellular fluid and/or ascites; or underfill may be due to vasodilatation of splanchnic bed (cf pregnancy—Nejm 1988;319:1127) and caused by excess nitric oxide production by endothelial cells (Nejm 1998;339:533). Budd-Chiari hepatic vein occlusion occurs
Sx:Abdominal swelling/edema
Si:Increased abdominal girth; fluid wave, shifting dullness, spiders, hepatosplenomegally
Pleural effusions, usually on R side from ascites leakage into chest (Am J Med 1999;107:262)
Spontaneous bacterial peritonitis (Nejm 1999;341:403); present in 20% of those admitted w ascites; dx by peritoneal fluid WBC counts >500 or PMNL >250 and cultures (Jama 2008;299:1166); rx w cefotaxime plus iv albumin to prevent hepatorenal syndrome
Lab:
Ascitic fluid:serum albumin level 
1.1 gm % greater than ascitic albumin level (Ann IM 1992;117:215), contrasts with malignant ascites (Am J Med 1984;77:83)
Bact:Ascitic fluid with pH <7.31 suggests peritonitis; cx fluid.
Chem:Hyponatremia in ascitics from hypovolemia-induced ADH (Ann IM 1982;96:413)
Rx:
Prophylaxis of spontaneous bacterial peritionitis in acute vericeal bleed w norfloxacin 400 mg po bid or 400 mg iv qd × 7 d, or w cipro 200 mg iv qd + Augmentin (w variceal bleed); in asx pt w cirrhosis: norflox 400 mg po qd + cipro 750 mg po q 1 wk and SS Tm/S 5 d/wk
of nontense ascites: Na restriction, furosemide iv/po, and amiloride or spironolactone up to 400 mg qd to achieve 1 kg/d loss if edema present; 0.3 kg qd if not
of tense ascites: