Here are four solid, clinically relevant studies tying ascites in cirrhosis to pain/symptom burden and showing symptom (incl. pain/discomfort) relief with effective drainage:

1. Liver Transplantation (Wong et al., 2020) — “Improvement in Quality of Life and Decrease in Large-Volume Paracentesis After Alfapump Implantation”
   Results: In 30 cirrhotic patients with recurrent ascites, alfapump markedly reduced paracentesis needs and significantly improved QoL (Ascites Questionnaire + CLDQ), which include abdominal discomfort/pain domains.
   URL: https://journals.lww.com/lt/fulltext/2020/05000/improvement_in_quality_of_life_and_decrease_in.9.aspx Lippincott Journals+1
   
   

2. United European Gastroenterology Journal (Mazumder et al., 2024) — “The physiological determinants of symptom burden in cirrhosis with ascites”
   Results: Symptom burden (including abdominal discomfort/pain) correlates with ascites pressure/volume; paracentesis is commonly used to relieve discomfort.
   URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC11578835/ PMC
   
   

3. Alimentary Pharmacology & Therapeutics (Macken et al., 2020) — “Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis (REDUCe)”
   Results: Feasibility RCT showed high symptom burden measured by IPOS and EQ-5D (includes pain/discomfort), with LTADs reducing hospital time and costs; qualitative data reported improved symptom control.
   URL: https://www.bsms.ac.uk/_pdf/ctu/reduce-results-paper.pdf Brighton and Sussex Medical School
   
   

4. Hepatology (Campbell et al., 2005) — “Quality of Life in Refractory Ascites: Transjugular Intrahepatic Portosystemic Shunt (TIPS)”
   Results: In refractory ascites, TIPS improved health-related QoL scores, including bodily pain domains, supporting that effective ascites control eases pain/discomfort.
   URL: https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.20840

⚠️ Note: This is educational only — dosing in liver failure is highly individualized and should be verified against the latest hepatology/pain guidelines.

1. Acetaminophen (Non-Opioid Analgesic)

• Acetaminophen (Tylenol) → Max 2 g/day (avoid chronic high-dose; safe in low dose with monitoring).
  
  

2. NSAIDs (Avoid in Cirrhosis/Ascites/Varices)

(generally contraindicated due to GI bleed, renal injury, and sodium retention risk)

• Ibuprofen → Avoid in decompensated liver disease.
  
  

• Naproxen → Avoid.
  
  

• Diclofenac → Avoid.
  
  

• Ketorolac → Avoid.
  
  

3. Weak Opioids

• Tramadol → 25–50 mg PO q8–12h (reduce dose/interval; risk of encephalopathy).
  
  

• Codeine → Avoid (variable metabolism, risk of accumulation).
  
  

4. Strong Opioids

(Use with caution; start low, go slow, prefer short-acting forms)

• Morphine → 2.5 mg PO/SC q4–6h (avoid if severe encephalopathy/renal issues).
  
  

• Hydromorphone → 0.5–1 mg PO/SC q4–6h (preferred over morphine; less active metabolites).
  
  

• Fentanyl (short-acting, IV/transdermal) → No active metabolites; safe option but start very low.
  
  

• Oxycodone → 2.5 mg PO q6h (reduce dose; impaired clearance in cirrhosis).
  
  

• Methadone → Specialist use only; prolonged half-life, requires careful titration.
  
  

5. Adjuvant Analgesics – Neuropathic Pain

• Gabapentin → 100 mg PO qHS (increase slowly; renally cleared, safe in liver).
  
  

• Pregabalin → 25–50 mg PO qHS (renal dosing; safe in liver).
  
  

• Duloxetine (SNRI) → Avoid in severe hepatic impairment.
  
  

• Amitriptyline (TCA) → 5–10 mg PO qHS (use caution; risk of sedation and encephalopathy).
  
  

6. Topical Agents

• Lidocaine 5% patch/gel → Apply up to 12h/day; minimal systemic absorption.
  
  

• Capsaicin cream/patch → Apply locally; safe, no hepatic metabolism concerns.
  
  

✅ Summary Principles in Liver Failure:

• Prefer acetaminophen (≤2 g/day) over NSAIDs.
  
  

• Use short-acting opioids at low doses; avoid codeine and meperidine.
  
  

• Favor adjuvants like gabapentin/pregabalin for neuropathic components.
  
  

• Topicals are very safe and useful.