What is the initial management of ascites?

Initial Management of Ascites

The initial management of ascites should consist of sodium restriction (90 mmol/day or 5.2 g salt/day) and oral diuretics, starting with spironolactone 100 mg/day, with the addition of furosemide 40 mg/day if necessary. 1, 2

Diagnostic Approach

• Perform a diagnostic paracentesis in all cirrhotic patients with ascites on hospital admission
• Inoculate ascitic fluid into blood culture bottles at bedside
• Analyze ascitic fluid for serum ascites-albumin gradient (SAAG), cell count, and culture

Treatment Algorithm

Step 1: Dietary Modification

• Implement a no-added-salt diet (90 mmol/day = 5.2 g salt/day)
• Bed rest is NOT recommended for treatment of ascites

Step 2: Diuretic Therapy

• First-line treatment: Spironolactone alone, starting at 100 mg/day as a single morning dose
• Titrate spironolactone upward every 3-5 days until natriuresis and weight loss are achieved
• Maximum dose of spironolactone: 400 mg/day
• If response is inadequate, add furosemide starting at 40 mg/day
• Titrate furosemide up to a maximum of 160 mg/day

Step 3: Management of Tense Ascites

• For patients with tense ascites, perform therapeutic paracentesis for rapid relief
• For paracentesis <5 liters: Use synthetic plasma expanders (150-200 ml of gelofusine or haemaccel)
• For paracentesis >5 liters: Administer albumin (8 g/liter of ascites removed)
• Follow paracentesis with dietary sodium restriction and diuretic therapy

Monitoring and Complications

Electrolyte Monitoring

• Monitor serum electrolytes and renal function every 3-5 days during dose adjustments
• Management of hyponatremia:
  • Na 126-135 mmol/L with normal creatinine: Continue diuretics with close monitoring
  • Na 121-125 mmol/L with normal creatinine: Consider reducing or stopping diuretics
  • Na 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion
  • Na <120 mmol/L: Stop diuretics and consider volume expansion

Potential Complications

• Hyperkalemia: Risk increases with spironolactone, especially in patients with renal impairment 3
• Renal impairment: Avoid NSAIDs as they can reduce sodium excretion and convert patients from diuretic-sensitive to diuretic-resistant 1, 2
• Hepatic encephalopathy: Can be precipitated by electrolyte disturbances or excessive diuresis

Refractory Ascites

Refractory ascites is defined as:

1. Unresponsive to sodium restriction and high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide), OR
2. Recurs rapidly after therapeutic paracentesis, OR
3. Development of diuretic-related complications preventing effective dosing 1, 2

Management options for refractory ascites:

• Serial therapeutic paracentesis with albumin replacement
• Consider TIPS (transjugular intrahepatic portosystemic shunt) in appropriate candidates
• Liver transplantation evaluation, as development of ascites indicates poor prognosis 2, 4

Special Considerations

• In patients with hepatic cirrhosis, initiate furosemide therapy in a hospital setting 5
• Sudden alterations of fluid and electrolyte balance in cirrhotic patients may precipitate hepatic coma 5
• Spironolactone can be temporarily withheld in patients with hypokalemia, common in alcoholic hepatitis 1
• Patients with parenchymal renal disease may tolerate less spironolactone due to hyperkalemia risk 1, 3

The development of ascites represents a significant landmark in cirrhosis progression and is associated with reduced survival, with only 50% of patients surviving 2-5 years after ascites development 4. Therefore, all patients with ascites should be considered for liver transplantation evaluation.