Ascites is the most common complication of decompensated cirrhosis, and in 2009 the American Academy of Liver Diseases (AASLD) developed guidelines on the management of ascites in adults with cirrhosis, which were published in Hepatology, the leading journal on liver disease. The purpose of the guidelines is to provide clinicians with a preferred approach to diagnosis, treatment, and prevention. In contrast to standard principles of treatment, the guidelines recommend that they should be applied flexibly on a case-by-case basis. In order to rate the basis of support for these recommendations, the Practice Guidelines Committee of the American Academy of Liver Diseases has given each recommendation a rating of evidence (reflecting benefit versus risk) and level (evaluating how strong or plausible it is) Its recommendations regarding diagnostic treatment are summarized below. Changjiang Liu, Department of Gastroenterology, Jinan Military General Hospital I. Recommendations for laparotomy 1. Laparotomy is required to obtain ascites (Class I, LevelC) in inpatients or outpatients with newly apparent ascites. 2. Routine prophylactic application of fresh frozen plasma or platelets prior to laparotomy is not recommended because bleeding is very rare (Class III, Level C). II. RECOMMENDATIONS FOR ASCITATIVE WATER ANALYSIS 3. Initial laboratory investigations of ascites should include ascites cell count and classification, total ascites protein, and serum-ascites albumin gradient (SAAG, calculated as serum albumin (g/L) – ascites albumin (g/L) (Class I, Level B). 4. If ascites infection is suspected, bedside blood culture bottles of ascites were performed before antibiotic administration (Class I, LevelB). 5. Additional tests may be performed to rule out the possible presence of other diseases (Class IIa, Level C). 6. Because serum CA125 testing does not contribute to the differential diagnosis of ascites, it is not recommended for the differential diagnosis of patients with any type of ascites (Class III, Level B). III. RECOMMENDATIONS FOR GENERAL TREATMENT OF ASSEMBLED HYDROPATHY 7. If liver damage in patients with ascites is associated with alcohol consumption, alcohol should be abstained from (Class I, Level B). 8. First-line treatment for patients with cirrhotic ascites includes sodium restriction (8 mmol/d or 2000 mg/d) and oral diuretics (oral spironolactone and/or furosemide) (Class IIa, Level A). 9. If blood sodium is less than 120-125 mmol/L, water intake should be restricted (Class III, Level C). 10. For large amounts of ascites, ascites can be drained by laparotomy, followed by restriction of sodium intake and oral diuretics (Class IIa, Level C). 11. If the patient is sensitive to diuretics, sodium intake restriction and oral diuretics should be used first without puncture and drainage of ascites (Class IIa, Level C). 12. Liver transplantation may be considered in cirrhotic patients with ascites (Class I, Level B). IV. RECOMMENDATIONS FOR THE TREATMENT OF INTENSE ASCITIC 13. Continuous therapeutic laparotomy may be an option (Class I, Level C). 14. If <4-5 L of fluid is drained at one time, albumin infusion may not be necessary (Class I, Level C) 15. If a large amount of ascites is drained, albumin infusion of 6-8 g per 1 L of ascites withdrawn should be performed (Class IIa, Level C). 16. Patients with persistent ascites should be considered for referral for liver transplantation as soon as possible (Class IIa, Level C). 17. Patients who meet the inclusion criteria of published randomized studies may be considered for transjugular intrahepatic portosystemic shunt (Class I, Level A). 18. patients who are not candidates for punctal ascites release, liver transplantation, or transjugular intrahepatic portosystemic shunt may be considered for abdominal-venous shunt by an experienced surgeon (Class IIb, Level A). V. RECOMMENDATIONS FOR THE TREATMENT OF HEPATOREPYNEPHRONIC SYNDROME 19.For type I hepatorenal syndrome, a combination of albumin and vasoactive drugs such as octreotide and midodrine may be applied (Class IIa, Level B). 20. Patients with hepatic ascites and type I hepatorenal syndrome should be referred for liver transplantation as soon as possible (Class I, Level B). VI. RECOMMENDATIONS FOR THE TREATMENT OF SPONSORY PERITONITIS 21. Hospitalized patients with ascites should undergo a laparotomy, which should be repeated (regardless of hospitalization) if the patient develops signs, symptoms, or laboratory tests suggestive of ascites infection (e.g., abdominal pain or muscle tension, fever, hepatic encephalopathy, renal failure, acidosis, or peripheral blood leukocytosis) (Class I, Level B ). 22. If the ascites polymorphonuclear leukocyte (PMN) count is ≥250 cells/mm3 (0.25 × 109/L), the patient should be treated with empiric anti-infective therapy such as a third-generation cephalosporin, preferably cefotaxime sodium 2 g/8 h (Class I, Level A). 23. Oral ofloxacin (400 mg bid) may be considered instead of cefotaxime sodium (Class IIa, Level B) in hospitalized patients with no prior history of quinolone use, no vomiting, shock, Grade 2 or higher hepatic encephalopathy, or blood creatinine >3 mg/dL. 24. Ascites with PMN counts ≥250 per mm3 (0.25 × 109/L) and signs or symptoms of infection (e.g., temperature >37.8°C or abdominal pain or muscle tension) should be treated with empiric anti-infective therapy, such as IV cefotaxime sodium 2 g/8 h (Class I, Level B), until blood culture results are reported. 25. If a patient with cirrhosis has an ascites PMN count of ≥250 per mm3 (0.25×109/L) and secondary peritonitis is highly suspected, ascites total protein, lactate dehydrogenase, sugar and Gram’s stains, carcinoembryonic antigen, and alkaline phosphatase should be performed to differentiate between SBP and secondary peritonitis (Class IIa, Level B). 26.In patients with ascites PMN counts ≥250 per mm3 (0.25 × 109/L) and clinical suspicion of SBP, albumin 1.5 g/kg may be applied within 6 h of the test if blood creatinine is >1 mg/dL, blood urea nitrogen is >30 mg/dL, or total bilirubin is >4 mg/dL, and 1.0 g/kg of albumin may be given on day 3 (Class IIa, Level B). Level B). VII. RECOMMENDATIONS FOR PREVENTION OF SPONTANEOUS PERITONITIS 27.Patients with cirrhosis who have gastrointestinal tract hemorrhage should be given intravenous ceftriaxone for 7 days or intravenous norfloxacin twice daily for 7 days to prevent bacterial infection (Class I, Level A). 28. Patients with a history of SBP episodes should be treated with daily norfloxacin (or methotrexate/sulfamethoxazole) for a long period of time to prevent recurrence (Class I, Level A). 29. In patients with cirrhotic ascites without gastrointestinal bleeding, long-term treatment with norfloxacin (or methotrexate/sulfamethoxazole) should be used if ascites protein is <1.5 g/dL and at least one of the following is present; blood creatinine >1.2 mg/dL, blood urea nitrogen >25 mg/dL, blood sodium <130 mEq/L, or Child-Pugh score >9, and serum bilirubin >3 mg/dL. methoxazole) prophylaxis (Class I, Level B). 30. Intermittent antibiotic prophylaxis for bacterial infections is less effective than daily antibiotic prophylaxis (due to the tendency to develop bacterial resistance), and therefore antibiotic prophylaxis should be given daily (Class IIb, Level C). Classification and Grading of Recommendations Classification Description Class Ⅰ A diagnosis, procedure, or treatment is useful and effective. Class Ⅱ The evidence for the usefulness and effectiveness of a particular diagnosis, procedure, or treatment is divided. Class Ⅱa There is a tendency to believe that a particular diagnosis, procedure or treatment is useful and effective. Class IIb Insufficient evidence of the usefulness and effectiveness of a diagnosis, procedure or treatment. Class III A diagnosis, procedure, or treatment is not useful, not effective, and in some cases may be harmful. Level A Information from a multicenter randomized clinical study or meta-analysis. Level B Information from single-center studies or non-randomized studies. Level C Expert consensus, case report, or practice.