Background: About 10% of patients with decompensated cirrhosis will develop refractory ascites, which indicates that their cirrhosis is progressing to a more severe stage. Significant hemodynamic alterations, starting with portal hypertension and progressing to renal hypoperfusion and excessive salt retention, are associated with its pathophysiology. Portal microthrombi, which inflammation can cause, keep the portal hypertension going and contribute to the pathophysiology of refractory ascites. Refractory ascites can lead to a number of problems, the most prevalent of which is renal failure. Preventing paracentesis-induced circulatory dysfunction begins with maintaining sodium restriction, which requires regular reviews to ensure adherence. Another component of management includes performing large-volume paracentesis (5 L or more) with albumin infusions on a regular basis. The therapy of these patients may use albumin infusions that are not dependent on paracentesis. If a patient is eligible and has a fair amount of liver reserve, a covered, smaller-diameter transjugular intrahepatic porto-systemic stent shunt (TIPS) can be inserted to improve quality of life and survival after ascites clearance. One potential future tool for treating ascites is an automated low-flow pump. Referral for liver transplant should be considered for patients with refractory ascites due to their poor prognosis. It is important to incorporate palliative care into the treatment plans of patients with advanced cirrhosis who are not candidates for definitive ascites control treatments in order to enhance their quality of life. Midodrine along with octreotide and albumin, has been shown to better control of ascites in a short-term pilot study in patients with refractory ascites.