What is the next step in managing cirrhosis with ascites?

Management of Ascites in Cirrhosis

The first-line treatment for ascites in cirrhosis should be spironolactone alone, starting at 100 mg/day and increasing to a maximum of 400 mg/day if needed. 1

Initial Assessment and Management

When managing a patient with cirrhosis and ascites, the following steps should be implemented:

1. Diagnostic paracentesis:

   • Obtain informed consent
   • Inoculate fluid into blood culture bottles at bedside
   • Examine fluid for neutrophil count
   • Calculate serum-ascites albumin gradient 2

2. Dietary modifications:

   • Restrict dietary salt to 90 mmol/day (5.2 g salt/day) - no added salt diet 2, 1
   • Ensure adequate protein intake (1.2-1.5 g/kg/day) 1

3. Pharmacological management:

   • Start spironolactone at 100 mg/day as the first-line agent 2, 1
   • Titrate dose upward as needed to a maximum of 400 mg/day 2, 3
   • If ascites fails to resolve with maximum spironolactone, add furosemide starting at 40 mg/day and increasing to a maximum of 160 mg/day 2, 1

Monitoring and Dose Adjustments

• Monitor serum electrolytes, creatinine, and weight regularly 1
• Target weight loss of 0.5 kg/day in patients without peripheral edema 1
• Adjust diuretic dosing based on:
  • Response (weight loss and reduction in ascites)
  • Electrolyte abnormalities
  • Renal function

Management of Hyponatremia

Hyponatremia requires careful management based on severity:

• Serum sodium 126-135 mmol/L with normal creatinine: Continue diuretics but monitor electrolytes closely; no water restriction needed 2, 1
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics or reducing dose 2, 1
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and provide volume expansion 2, 1
• **Serum sodium <120 mmol/L**: Stop diuretics; consider volume expansion with colloid or saline; avoid increasing serum sodium by >12 mmol/L per 24 hours 2, 1

Management of Refractory Ascites

For patients who fail to respond to maximum doses of diuretics (spironolactone 400 mg/day plus furosemide 160 mg/day) for at least one week:

1. Therapeutic paracentesis:

   • First-line treatment for patients with large or refractory ascites 2
   • For paracentesis <5 liters: Follow with synthetic plasma expander (150-200 ml of gelofusine or haemaccel) 2
   • For large volume paracentesis: Administer albumin (8 g per liter of ascites removed) 2, 1

2. Consider TIPS (Transjugular Intrahepatic Portosystemic Shunt):

   • For patients requiring frequent therapeutic paracentesis 2, 1
   • Use caution in patients with advanced age, elevated bilirubin, low platelets, high MELD score, or hepatic encephalopathy 1

3. Liver transplantation evaluation:

   • All patients with ascites should be considered for liver transplantation evaluation 2, 1
   • Development of ascites is an important milestone indicating poor prognosis 2, 4

Common Pitfalls to Avoid

• Starting with loop diuretics alone rather than spironolactone 1, 5
• Excessive diuresis leading to renal dysfunction 1
• Using NSAIDs, ACE inhibitors, or angiotensin receptor blockers, which can worsen ascites 1
• Unnecessary water restriction in patients with uncomplicated ascites 2, 1
• Failure to monitor electrolytes and renal function during diuretic therapy 1

Special Considerations

• Spontaneous bacterial peritonitis (SBP): Patients recovering from SBP should receive prophylaxis with norfloxacin 400 mg/day or ciprofloxacin 500 mg once daily 2
• Hepatorenal syndrome: Requires careful management with volume expansion and potentially vasoconstrictors 1
• Tense ascites: Perform therapeutic paracentesis followed by diuretic therapy 1, 6

By following this algorithmic approach to managing ascites in cirrhosis, clinicians can optimize outcomes while minimizing complications, ultimately improving patient quality of life and potentially reducing mortality.