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

Initial Management of Ascites in Cirrhosis

The initial management of ascites should consist of sodium restriction (approximately 5-6.5g salt/day) and oral diuretics, starting with spironolactone monotherapy for first presentation of moderate ascites, with the addition of furosemide if necessary for recurrent or severe ascites. 1, 2

Diagnostic Approach

• Perform diagnostic paracentesis in all patients with new-onset ascites to:
  • Determine serum-ascites albumin gradient (SAAG)
  • Obtain cell count and differential
  • Culture fluid to rule out spontaneous bacterial peritonitis (SBP)
• Ultrasound guidance should be considered when available to reduce risk of adverse events 2
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 2

Treatment Algorithm

Step 1: Dietary Sodium Restriction

• Implement a moderately salt-restricted diet with daily sodium intake of 5-6.5g (87-113 mmol) 2
• This translates to a no-added salt diet with avoidance of precooked meals
• Provide nutritional counseling on sodium content in diet 2

Step 2: Diuretic Therapy

• First presentation of moderate ascites:

  • Start with spironolactone monotherapy 100mg daily 2, 1
  • Titrate dose upward as needed to maximum 400mg daily

• Recurrent or severe ascites (or if faster diuresis needed):

  • Combination therapy with spironolactone (100mg, up to 400mg) and furosemide (40mg, up to 160mg) 2
  • Administer both medications as a single morning dose to maximize compliance 1
  • Target weight loss of 300-500g/day in patients without peripheral edema 3

Step 3: Large Volume Paracentesis (LVP)

• For patients with tense ascites, perform therapeutic paracentesis for rapid symptom relief 1
• Albumin (20% or 25% solution) should be infused after paracentesis of >5L at a dose of 8g albumin/L of ascites removed 2
• Consider albumin infusion even for paracentesis <5L in patients with acute-on-chronic liver failure 2

Monitoring and Management of Complications

Diuretic-Related Complications

• Monitor serum electrolytes and renal function regularly during dose adjustments 1
• Hypovolemic hyponatremia: Discontinue diuretics and expand plasma volume with normal saline 2
• Fluid restriction (1-1.5L/day): Reserve for hypervolemic patients with severe hyponatremia (serum sodium <125 mmol/L) 2
• Hypertonic sodium chloride (3%): Reserve for severely symptomatic patients with acute hyponatremia 2

Prevention of SBP

• Patients with gastrointestinal bleeding and ascites should receive prophylactic antibiotics 2
• Patients who have recovered from SBP should receive secondary prophylaxis with norfloxacin (400mg daily), ciprofloxacin (500mg daily), or co-trimoxazole 2
• Primary prophylaxis should be offered to high-risk patients (ascitic protein <1.5 g/dL) 2

Management of Refractory Ascites

• Defined as ascites that does not respond to sodium restriction and maximum doses of diuretics (spironolactone 400mg/day and furosemide 160mg/day) 4
• Options include:
  • Serial therapeutic paracentesis with albumin replacement
  • Consider midodrine in selected cases 2
  • Transjugular intrahepatic portosystemic shunt (TIPS) for appropriate candidates 5
  • Liver transplantation evaluation (offers definitive treatment) 5

Important Cautions

• Avoid NSAIDs as they can reduce sodium excretion and convert diuretic-sensitive patients to diuretic-resistant 1, 6
• In hepatic cirrhosis with ascites, diuretic therapy is best initiated in the hospital setting 7
• Sudden alterations in fluid and electrolyte balance may precipitate hepatic encephalopathy 7
• Approximately 10% of patients fail to respond to diuretics and become a therapeutic challenge 5
• Spironolactone acts as an aldosterone antagonist, counteracting secondary aldosteronism induced by volume depletion 8

The management of ascites requires careful monitoring and adjustment of therapy based on patient response, with the goal of improving mortality, morbidity, and quality of life through effective fluid management while preventing complications.