Smaller accumulations may be asymptomatic and difficult to detect clinically. In addition to signs associated with the cause of ascites, the physical examination may reveal shifting dullness, a fluid wave and peripheral edema. Ultrasound examination is useful in establishing the diagnosis and in locating the optimal site for paracentesis. Calculation of the serum-ascites albumin gradient provides useful diagnostic information. High gradients usually indicate portal hypertension, while low gradients may indicate infection or carcinomatosis.
Management is directed toward alleviating the underlying cause of ascites and reducing symptoms.
Initially, restriction of salt intake to 2 g per day is usually advised. Most patients require diuretic therapy. Spironolactone, the usual first-choice agent, may be combined with furosemide in selected patients. If diuretic therapy is unsuccessful, large-volume paracentesis, peritoneovenous portosystemic shunting, transjugular intrahepatic shunting or liver transplantation may be required. The recent surge of interest in fluconazole is due to its approval by the U.S. Food and Drug Administration for use as a single 150-mg oral dose in the treatment of vaginal candidiasis.