What is the treatment for ascites, particularly in patients with cirrhosis?

Treatment of Ascites in Cirrhosis

The first-line treatment for patients with cirrhosis and ascites consists of sodium restriction (88 mmol/day [2000 mg/day]) and diuretics (oral spironolactone and furosemide). 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Diagnostic paracentesis should be performed in all cirrhotic patients with ascites on hospital admission 1

   • Include ascitic fluid cell count and differential
   • Measure serum-ascites albumin gradient (SAAG)
   • Culture ascitic fluid at bedside in blood culture bottles if infection is suspected

2. Laboratory evaluation

   • SAAG ≥1.1 g/dL indicates portal hypertension 1
   • Ascitic fluid should be examined for neutrophil count to rule out spontaneous bacterial peritonitis (SBP)

Treatment Algorithm

First-Line Treatment

1. Dietary sodium restriction

   • Limit to 88-90 mmol/day (2000 mg/day) 1, 2
   • No added salt diet

2. Diuretic therapy

   • Initial approach: Start with spironolactone alone 100 mg/day 1, 2, 3
   • Increase spironolactone gradually up to 400 mg/day if needed 1
   • If inadequate response, add furosemide 20-40 mg/day, which can be increased up to 160 mg/day 1, 4
   • Target weight loss: 300-500 g/day in patients without peripheral edema 5

Management of Tense Ascites

1. Large volume paracentesis (LVP) for patients with tense ascites 1
   • Follow with sodium restriction and oral diuretics to prevent reaccumulation
   • Volume expansion is required:
     • For paracentesis <5 liters: synthetic plasma expander (150-200 ml of gelofusine or haemaccel) 1
     • For paracentesis >5 liters: albumin (8 g/L of ascites removed) 1, 6

Management of Refractory Ascites

Refractory ascites is defined as:

• Unresponsive to sodium restriction and high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide) 1
• Or recurs rapidly after therapeutic paracentesis

Treatment options:

1. Serial therapeutic paracentesis with albumin replacement 1
2. Transjugular intrahepatic portosystemic shunt (TIPS) for patients requiring frequent paracentesis 1, 6
   • Best for patients with relatively preserved liver function
3. Liver transplantation evaluation 1, 2

Special Considerations

Hyponatremia Management

• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1
• For serum sodium 121-125 mmol/L with normal creatinine: consider stopping diuretics 1
• For serum sodium <120 mmol/L: stop diuretics and consider volume expansion 1

Spontaneous Bacterial Peritonitis (SBP)

• Empiric antibiotic therapy should be started if ascitic fluid neutrophil count >250 cells/mm³ 1
• Third-generation cephalosporins are recommended 1
• All patients with SBP should be considered for liver transplantation 1

Monitoring and Follow-up

• Monitor weight, urinary sodium excretion, serum electrolytes, and renal function 1
• Frequency of follow-up depends on response to treatment and patient stability 1
• Initial evaluation every 2-4 weeks until stable, then every few months 1

Important Cautions

• Avoid NSAIDs and other prostaglandin inhibitors as they can reduce urinary sodium excretion and induce azotemia 1, 2
• Avoid nephrotoxic drugs in patients with ascites 2
• Bed rest is not recommended for treatment of ascites 1
• For patients with alcoholic liver disease, abstinence from alcohol is crucial for improving outcomes 1, 5

Long-term Management

• Liver transplantation should be considered in all patients with cirrhotic ascites, as it is the ultimate treatment for ascites and its complications 1, 2
• Development of ascites is an important landmark in the natural history of cirrhosis and should be considered as an indication for transplantation evaluation 1, 2