About 85% of all patients with ascites are due to cirrhosis. Ascites is the most common of the three major complications of cirrhosis. About 50% of patients with compensated cirrhosis develop ascites within 10 years, and the development of ascites is an important milestone in the course of liver disease, as the morbidity and mortality rate is significantly higher in those with ascites. Analysis of ascites fluid by laparotomy is the most rapid and effective method to diagnose the cause of ascites. SAAG [serum ascites albumin gradient (g/dl)] = serum albumin (g/dl) – ascites albumin (g/dl) is the most effective laboratory test to differentiate portal hypertensive ascites from non-portal hypertensive ascites, with an accuracy rate of 97%. non-portal hypertensive ascites. If the patient has portal hypertension and other causes of ascites, the SAAG is still greater than or equal to 1.1 g/dl. In patients with suspected ascites infection, ascites culture, ascites Gram stain and other relevant tests should be performed. Ascites culture should be performed by drawing ascites fluid at the patient’s bedside and immediately injecting it into a blood culture bottle for culture, which can greatly improve the positive rate of ascites culture. The following are key elements of the American College of Hepatology guidelines for the treatment of cirrhotic ascites: Indications for laparotomy: 1. Inpatients and outpatients with clinically significant new ascites should undergo laparotomy and have ascites fluid retained. 2, Prophylactic application of fresh frozen plasma or platelets prior to laparotomy is not recommended because of the low potential for bleeding. 3, Initial laboratory tests for ascites should include ascites cell count and classification, total ascites protein, and SAAG. 4, If infection is suspected in the ascites, ascites culture should be performed at the bedside with a blood culture bottle. 5.To confirm the suspected possible disease, other tests may be performed. Treatment of cirrhotic ascites: Effective treatment relies on therapy that addresses the cause of ascites. Alcohol-induced liver injury is the most easily reversible of all liver diseases that cause portal hypertension. The most important treatment for such patients is abstinence from alcohol. Significant improvement in alcoholic liver disease can be seen within a few months of abstinence, and in patients with ascites, the ascites can subside significantly or become more responsive to medications. Non-alcoholic liver disease is not easily reversible. When ascites is present, such patients are best placed on a waiting list for liver transplantation rather than relying on medication alone. Treatment of cirrhotic ascites consists mainly of restricting sodium intake [to no more than 88 mmol/day (2000 mg/day)] and oral diuretics. The treatment of cirrhotic ascites does not require restriction of water intake unless severe hyponatremia is present. Chronic hyponatremia is common in patients with cirrhosis, but patients rarely die as a result. Too rapid correction of hyponatremia can lead to more serious complications, therefore, only if the blood sodium is 250/mm3) and there is no intra-abdominal, surgically treatable source of infection. Ninety-five percent of spontaneous bacterial peritonitis is caused by three bacteria, Escherichia coli, Klebsiella pneumoniae, and pneumococci, and therefore the antibiotic spectrum for empiric therapy should include these three common causative agents. The first choice for empiric treatment is a third-generation cephalosporin, such as cefotaxime, 2 g, every 8 hours, intravenously. Combined application of intravenous albumin infusion along with antibiotics. 19, inpatients with ascites are examined by laparotomy. Patients with signs and symptoms suggestive of ascites infection and abnormal laboratory tests (e.g., abdominal pain or myalgias, fever, hepatic encephalopathy, renal failure, acidosis, or peripheral leukocytosis) should undergo repeat laparotomy (whether or not they are hospitalized). 20, Patients with ascitic fluid neutrophil (PMN) counts ≥250/mm3 (0.25 × 109/L) should receive empiric anti-infective therapy such as intravenous cefotaxime 2 g every 8 hours. 21, When the ascites PMN count is 2.5 mg/dl, it is reasonable to apply quinolones either short-term (for inpatients only) or long-term daily.