What is the initial management of ascites (fluid accumulation in the peritoneal cavity) in patients with cirrhosis?

Initial Management of Ascites in Cirrhosis

The initial management of ascites in patients with cirrhosis should begin with a diagnostic paracentesis followed by sodium restriction and diuretic therapy, starting with spironolactone monotherapy for first presentation of moderate ascites. 1

Diagnostic Approach

• A diagnostic paracentesis is mandatory in all patients with new-onset ascites to establish the diagnosis and rule out spontaneous bacterial peritonitis (SBP) 1
• Initial ascitic fluid analysis should include:
  • Total protein concentration and calculation of serum ascites albumin gradient (SAAG) - a SAAG ≥11 g/L indicates portal hypertension 1
  • Cell count with differential to rule out SBP (neutrophil count >250/mm³ is diagnostic of SBP) 1
  • Ascitic fluid culture with bedside inoculation of blood culture bottles when SBP is suspected 1
• Additional tests to consider based on clinical suspicion:
  • Cytology (if malignancy suspected)
  • Amylase (if pancreatic disease suspected)
  • Adenosine deaminase (if tuberculosis suspected) 1

First-Line Treatment

Dietary Sodium Restriction

• Implement moderately salt-restricted diet with daily salt intake of no more than 5-6.5g (87-113 mmol sodium) 1
• This translates to a "no added salt" diet with avoidance of precooked meals 1
• Nutritional counseling on sodium content in diet should be provided 1

Diuretic Therapy

• For first presentation of moderate ascites:
  • Start with spironolactone monotherapy at 100 mg/day, which can be increased up to 400 mg/day 1
  • If response is inadequate, add furosemide starting at 40 mg/day, which can be increased up to 160 mg/day 1
• For recurrent severe ascites or when faster diuresis is needed (e.g., hospitalized patients):
  • Use combination therapy with spironolactone (100-400 mg/day) and furosemide (40-160 mg/day) 1

Monitoring and Complications

• All patients initiating diuretics should be monitored for adverse events, as almost half experience complications requiring dose reduction or discontinuation 1
• Watch for hyponatremia, which can occur during diuretic therapy 1
• In patients with hepatic cirrhosis and ascites, furosemide therapy should be initiated in the hospital setting 2
• Sudden alterations of fluid and electrolyte balance in cirrhosis may precipitate hepatic encephalopathy 2

Management of Spontaneous Bacterial Peritonitis

• Diagnostic paracentesis should be performed without delay to rule out SBP in all cirrhotic patients with ascites on hospital admission 1
• Additional indications for paracentesis include:
  • GI bleeding
  • Fever or other signs of systemic inflammation
  • Abdominal pain or gastrointestinal symptoms
  • Hepatic encephalopathy
  • Worsening liver or renal function 1, 3
• Immediate empirical antibiotic therapy should be started when SBP is diagnosed (neutrophil count >250/mm³) 1
• Cefotaxime has been widely studied but antibiotic choice should be guided by local resistance patterns 1

Special Considerations

• Removal of ascitic fluid may cause cardiovascular changes and potentially hypovolemic shock; albumin infusion may be required to support blood volume 4
• For large-volume paracentesis (>5 liters), albumin administration (8g per liter of ascites removed) is recommended to prevent post-paracentesis circulatory dysfunction 1, 5
• Patients with refractory ascites (not responding to maximum doses of diuretics) should be considered for second-line treatments such as repeated large-volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS) 5, 6
• All patients with ascites due to cirrhosis should be evaluated for liver transplantation 1, 6

Common Pitfalls to Avoid

• Delaying diagnostic paracentesis, which can increase mortality (each hour of delay is associated with a 3.3% increase in hospital mortality) 1
• Failing to screen for SBP in hospitalized cirrhotic patients with ascites 1, 3
• Inadequate sodium restriction, which can limit the effectiveness of diuretic therapy 1
• Overly aggressive diuresis, which can lead to electrolyte abnormalities, renal dysfunction, or hepatic encephalopathy 2