What is the management approach for a patient presenting with ascites?

Management Approach for Ascites

The management of ascites should begin with diagnostic paracentesis to determine the cause, followed by sodium restriction (5-6.5g/day) and diuretic therapy (starting with spironolactone 100mg daily, potentially adding furosemide 40mg daily), with large volume paracentesis for tense ascites. 1

Initial Evaluation and Diagnosis

Diagnostic Paracentesis

• Perform diagnostic paracentesis in all patients with new-onset ascites or hospitalized for worsening ascites 1
• Essential tests on ascitic fluid:
  • Serum-ascites albumin gradient (SAAG): ≥1.1 g/dL indicates portal hypertension 1
  • Total protein concentration: <15 g/L indicates increased risk of SBP 1
  • Cell count with neutrophil differential: >250/mm³ neutrophils diagnoses SBP 1
  • Ascitic fluid culture (bedside inoculation into blood culture bottles) 1

Additional Testing

• Abdominal ultrasound to evaluate liver and rule out other causes 1
• Laboratory assessment of liver function, renal function, and serum/urine electrolytes 1
• Consider specialized tests (amylase, cytology, etc.) if non-cirrhotic causes suspected 1

Treatment Algorithm

First-Line Treatment

1. Dietary sodium restriction:

   • Moderate salt restriction (5-6.5g/day or 87-113 mmol sodium/day) 1
   • Avoid precooked meals and no added salt diet 1
   • Provide nutritional counseling on sodium content 1

2. Diuretic therapy:

   • For first presentation of moderate ascites: Spironolactone monotherapy (starting at 100mg daily, can increase to 400mg) 1
   • For recurrent or severe ascites: Combination therapy with spironolactone (100-400mg) and furosemide (40-160mg) 1
   • Maintain 100mg:40mg ratio of spironolactone to furosemide to maintain normokalemia 1
   • Increase doses every 3-5 days until adequate natriuresis and weight loss achieved 1

Management of Tense Ascites

• Perform large volume paracentesis (LVP) for rapid relief 1
• For volumes >5L, administer intravenous albumin (8g/L of fluid removed) to prevent post-paracentesis circulatory dysfunction 1
• Follow LVP with sodium restriction and diuretic therapy to prevent reaccumulation 1

Management of Refractory Ascites

Defined as ascites unresponsive to sodium restriction and high-dose diuretics (400mg spironolactone + 160mg furosemide) or recurs rapidly after therapeutic paracentesis 1

Options include:

1. Serial therapeutic paracenteses with albumin replacement
2. Consider transjugular intrahepatic portosystemic shunt (TIPS) in selected patients
3. Evaluation for liver transplantation 1

Management of Complications

Spontaneous Bacterial Peritonitis (SBP)

• Immediate empirical antibiotic therapy when SBP is suspected 1
• Consider secondary prophylaxis with norfloxacin (400mg daily), ciprofloxacin (500mg daily), or co-trimoxazole after recovery from SBP 1
• Primary prophylaxis for high-risk patients (ascitic protein <1.5 g/dL) 1

Hyponatremia

• Fluid restriction (1-1.5L/day) only if severe hyponatremia (serum sodium <125 mmol/L) 1
• For hypovolemic hyponatremia: discontinue diuretics and expand plasma volume with normal saline 1
• For severe symptomatic hyponatremia: consider hypertonic saline (3%) with slow correction 1

Monitoring and Follow-up

• Monitor weight, urinary sodium excretion, renal function, and electrolytes
• 24-hour urinary sodium >78 mmol/day indicates adequate natriuresis 1
• Adjust diuretic doses based on response and adverse effects
• Consider early outpatient follow-up (within 1 week) after hospital discharge 1

Common Pitfalls to Avoid

1. Avoid NSAIDs as they can reduce urinary sodium excretion and induce azotemia, converting diuretic-sensitive patients to refractory 1
2. Avoid excessive salt restriction (<5g/day) as it can lead to hyponatremia, reduced caloric intake, and increased risk of renal impairment 1
3. Avoid routine fluid restriction unless serum sodium is <125 mmol/L 1
4. Don't delay diagnostic paracentesis when SBP is suspected 1
5. Avoid serial paracenteses in diuretic-sensitive patients when ascites could be managed with diuretics 1

Remember that the development of ascites is associated with poor prognosis in cirrhosis, and patients should generally be considered for liver transplantation evaluation 1.