The treatment of severe cirrhotic ascites is still a major clinical problem. On the basis of the current recommendations for treatment in the textbooks we have reviewed the randomized clinical trials comparing the existing different options of treatment. It is concluded that paracentesis is marked by several advantages compared to diuretics. Paracentesis has to be followed by an intravenous infusion of a volume expander to avert hypovolaemic complications and can then be performed as total paracentesis. The effect has to be maintained by diuretics. Synthetic products of low cost may substitute albumin. Intravenous reinfusion of ascites fluid constitutes a viable alternative. Under diuretic treatment spironolactone (in doses up to 400 mg daily) should be preferred to furosemide. Combinations of diuretics offer no advantages. The value of sodium restriction although rational is not documented in randomized trials. Sodium restriction is difficult to comply with and is not crucial for the therapeutic effect when diuretics are being administered at the same time. The advantages of a peritoneovenous shunt are outweighed by the very frequent incidence of shunt occlusion, for which reason the application should be restricted.