The best treatment for a refractory ascites is to perform a liver transplantation if there is not local , general or age-dependent contraindications. If they are present a TIPS is a good temporary measure

I use at first paracentesis, then intravenous alpha lipoic acid on a regular basis.

This often reverses the condition.

You may want to go PubMed and type in

Berkson BM, or Google Scholar, or Google Berkson BM.

There are some full-text papers there.

In addition you may want to Google Berkson, National Cancer Institute.

Burton M. Berkson MD, MS, Ph.D.

The Integrative Medical Center of New Mexico

1-575-524-3720

You may find it useful to look at the relevant info in these EASL practice guidelines-

http://www.easl.eu/research/our-contributions/clinical-practice-guidelines/detail/management-of-ascites-spontaneous-bacterial-peritonitis-and-hepatorenal-syndrome-in-cirrhosis

First it depends on cause. For that caused by chronic liver failure, please look into the definition of refractory ascites as given by International Ascites Club criteria. In such cases it is a terminal manifestation associated with HRS and repeated paracentesis, TIPS insertion or liver transplantation may help.

Ascites may also be felt refractory if it does not respond to treatment of diurectics/fluid restriction etc. In such cases, there may be underlying condition like different intra abdominal cancers with peritoneal metastasis, primary peritoneal cancers,cardiac failure, hypothyroidism, constrictive pericarditis, Budd Chiari syndrome, tuberculosis etc which must be diagnosed ant treated for response.

Dear Dr Amr,

When you speak about refractory ascites, you mean that you are dealing with an ascites that cannot be mobilized or that early recur (i.e., after therapeutic paracentesis) and cannot be satisfactorily prevented by medical therapy. At this stage the step-wise approach is:

1-      Repeated large volume paracentesis

2-      TIPS

3-      Liver transplantation

However, please do not miss treatment of the cause as many etiologies can improve when receiving the specific treatment even after reaching this advanced stage; like autoimmune hepatitis and  Wilson disease.