What is the best approach for managing ascites?

Management of Ascites in Cirrhosis

The best approach for managing ascites in cirrhosis is a stepwise treatment starting with sodium restriction and diuretic therapy, followed by therapeutic paracentesis for refractory cases, with liver transplantation being the ultimate definitive treatment. 1

Initial Diagnostic Approach

• Perform diagnostic paracentesis in all cirrhotic patients with ascites on hospital admission
• Inoculate ascitic fluid into blood culture bottles at bedside
• Include serum ascites-albumin gradient in initial fluid analysis
• Measure ascitic neutrophil count to rule out spontaneous bacterial peritonitis (SBP)

First-Line Management

Dietary and Lifestyle Modifications

• Restrict sodium intake to 80-120 mmol/day (4.6-6.9 g salt/day), equivalent to a no-added salt diet 1
• Fluid restriction is not necessary for patients with normal serum sodium 1
• Bed rest is not recommended for treatment of ascites 1

Diuretic Therapy

1. Initial Presentation (Moderate Ascites):

   • Start with spironolactone monotherapy 100 mg/day, increasing gradually to maximum 400 mg/day 1
   • Titrate dose every 7 days as aldosterone antagonists have slow onset of action 1

2. Recurrent or Severe Ascites:

   • Combination therapy with spironolactone (100-400 mg/day) and furosemide (40-160 mg/day) 1
   • Maintain 100:40 mg ratio of spironolactone to furosemide to maintain normokalemia 1
   • Adjust to achieve weight loss of 0.5 kg/day without peripheral edema or 1 kg/day with peripheral edema 1

3. Monitoring During Diuretic Therapy:

   • Monitor serum electrolytes, renal function, and weight regularly
   • Watch for complications: hyperkalemia, hyponatremia, renal impairment, hepatic encephalopathy 2, 3

Management of Hyponatremia

• Serum sodium 126-135 mmol/L with normal creatinine: Continue diuretics, monitor electrolytes 1
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics 1
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics, give volume expansion 1
• Serum sodium <120 mmol/L: Stop diuretics, consider volume expansion with colloid or saline 1, 4
• Fluid restriction (1-1.5 L/day) only for severe hyponatremia (serum sodium <125 mmol/L) 1, 4
• Avoid increasing serum sodium by >12 mmol/L per 24 hours 1

Management of Refractory Ascites

Refractory ascites occurs in approximately 10% of patients and is defined as ascites unresponsive to sodium restriction and high-dose diuretics, or when diuretics cannot be used due to adverse effects 5, 6.

Therapeutic (Large Volume) Paracentesis

• First-line treatment for patients with large or refractory ascites 1
• Perform complete drainage in a single session 1
• Volume expansion guidelines:
  • For <5 liters removed: Use synthetic plasma expander (150-200 ml of gelofusine or haemaccel) 1
  • For large volume paracentesis: Administer albumin (8 g/L of ascites removed) 1
• Can be safely performed in outpatient setting by trained healthcare providers 1

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• Consider for patients requiring frequent therapeutic paracentesis or with hepatic hydrothorax 1
• Most appropriate for patients with relatively preserved liver function 5
• Assess risk-benefit ratio carefully as complications include hepatic encephalopathy 1

Other Approaches

• Midodrine (α-adrenergic agonist) may be considered on a case-by-case basis for refractory ascites 1
• Peritoneovenous shunts have limited use due to high complication rates 7

Prophylaxis and Management of Complications

Spontaneous Bacterial Peritonitis (SBP)

• Patients recovering from SBP should receive prophylaxis with norfloxacin 400 mg/day or ciprofloxacin 500 mg once daily 1
• All patients with SBP should be considered for liver transplantation 1

Definitive Treatment

• Liver transplantation is the ultimate treatment for ascites and its complications 1, 5, 8
• Development of ascites should be considered an indication for transplantation evaluation 1
• Transplantation offers definitive cure for cirrhosis and significantly improves survival 8

Common Pitfalls to Avoid

• Excessive diuresis leading to hypovolemia, renal impairment, or electrolyte disturbances
• Inadequate monitoring of electrolytes during diuretic therapy
• Delayed recognition of refractory ascites and need for alternative treatments
• Failure to consider liver transplantation evaluation when ascites first develops
• Rapid correction of hyponatremia (should not exceed 12 mmol/L in 24 hours) 1
• Using hydrochlorothiazide with spironolactone and furosemide, which can cause rapid hyponatremia 1