What is the best approach to manage a patient with ascites?

Management of Ascites in Cirrhosis

The first-line treatment for patients with cirrhosis and ascites consists of sodium restriction (88 mmol/day or 2000 mg/day) combined with diuretic therapy using oral spironolactone and furosemide. 1

Initial Assessment and Management

For First Presentation of Moderate Ascites:

1. Sodium restriction:

   • Recommend salt intake of 5-6.5 g/day (87-113 mmol/day) 1
   • This typically corresponds to a no-added salt diet with avoidance of pre-prepared meals 1

2. Diuretic therapy:

   • First episode of ascites: Start with spironolactone 100 mg/day alone, increasing in stepwise manner every 7 days up to 400 mg/day if needed 1
   • Recurrent ascites: Begin with combination therapy of spironolactone 100 mg/day and furosemide 40 mg/day 1
   • Increase doses every 3-5 days (maintaining 100 mg:40 mg ratio) if response is inadequate 1
   • Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1

3. For tense ascites:

   • Perform initial therapeutic paracentesis for rapid symptom relief 1
   • A single 5-L paracentesis can be performed safely without post-paracentesis colloid infusion 1
   • For larger volumes (>5L), administer intravenous albumin (8 g/L of fluid removed) 1, 2
   • Follow paracentesis with sodium restriction and diuretic therapy 1

Monitoring and Targets

• Target weight loss:

  • 0.5 kg/day in patients without peripheral edema 1
  • 1 kg/day in patients with peripheral edema 1

• Diuretic response monitoring:

  • Aim for urinary sodium excretion >78 mmol/day 1
  • A random spot urine sodium:potassium ratio between 1.8-2.5 can predict adequate sodium excretion 1

• Monitor for complications:

  • Electrolyte imbalances (hyponatremia, hypo/hyperkalemia)
  • Renal dysfunction (serum creatinine >2.0 mg/dL)
  • Hepatic encephalopathy
  • Muscle cramps 1

Management of Complications

Hyponatremia:

• Fluid restriction is not necessary unless serum sodium <120-125 mmol/L 1
• Temporarily discontinue diuretics if serum sodium <125 mmol/L 1
• For hypovolemic hyponatremia (from overzealous diuretic therapy): expand plasma volume with normal saline and stop diuretics 1

Refractory Ascites:

Defined as ascites that:

1. Is 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. Develops significant complications that prevent effective diuretic dosing 1, 2

Management options:

• Serial therapeutic paracenteses (approximately every 2 weeks) 1
• Consider TIPS (transjugular intrahepatic portosystemic shunt) for patients requiring frequent paracenteses with preserved liver function 2
• Liver transplantation evaluation for all patients with refractory ascites 2

Important Considerations

• Avoid NSAIDs as they reduce diuretic efficacy and can induce renal dysfunction 2
• Furosemide warnings: In patients with hepatic cirrhosis, therapy is best initiated in hospital. Sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 3
• After resolution of ascites: Reduce diuretic dose to the lowest effective dose 1
• Liver transplantation should be considered in all patients with cirrhosis and ascites 1

Pitfalls to Avoid

1. Overly aggressive diuresis can lead to hypovolemia, renal dysfunction, and hepatic encephalopathy
2. Inadequate monitoring of electrolytes and renal function
3. Failure to recognize refractory ascites early and adjust management strategy
4. Relying solely on serial paracenteses without addressing underlying sodium retention
5. Continuing NSAIDs in patients with ascites, which can convert diuretic-sensitive to refractory ascites 1

Remember that successful treatment depends on accurate diagnosis of the cause of ascites, with cirrhosis accounting for approximately 85% of all cases 4. The development of ascites in cirrhosis indicates poor prognosis, with only 50% of patients surviving 2-5 years after its development 4.