What are the indications for referring a patient with ascites to secondary care for further management?

Referral to secondary care for a patient with ascites is indicated in several situations:

• Decompensated Liver Disease: If a person has signs of decompensated liver disease, which includes ascites, arrange emergency hospital admission or immediate referral to a hepatologist or gastroenterologist with an interest in hepatology ¹. An urgent specialist nurse-led liver clinic may also be appropriate to avoid admission, depending on the patient's presentation, care plan, and local service provision ¹.
• Refractory Ascites: For people with cirrhosis who have refractory ascites, a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure may be considered ³. Nurse-led day case paracentesis services for refractory ascites can also reduce emergency hospital admissions ¹.
• High Risk of Spontaneous Bacterial Peritonitis (SBP): Specialist treatment with prophylactic antibiotics may be considered if a person has ascites and is considered at high risk of infection, or if the consequences of infection could severely impact their outcome and care ¹.
• Suspected Ovarian Cancer: In women, if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids), refer the woman using a suspected cancer pathway referral ⁴,⁵.