Initial Management of Ascites Due to Portal Hypertension
The initial management of ascites due to portal hypertension should focus on dietary sodium restriction (2000 mg/day or 88 mmol/day) and oral diuretics, typically starting with spironolactone 100 mg daily and furosemide 40 mg daily. 1, 2
Diagnostic Approach
- Perform a diagnostic paracentesis to confirm portal hypertension as the cause of ascites by measuring the serum-ascites albumin gradient (SAAG) 1
- A SAAG ≥1.1 g/dL indicates portal hypertension with approximately 97% accuracy 1, 3
- Additional ascitic fluid tests should include cell count, differential, total protein, and culture if infection is suspected 1
- Avoid testing serum for CA125, as it is elevated in all patients with ascites regardless of cause and may lead to unnecessary procedures 1
First-Line Treatment
Dietary Modifications
- Restrict sodium intake to 2000 mg/day (88 mmol/day) 1, 2
- More stringent sodium restriction can speed mobilization of ascites but is not recommended as it may worsen malnutrition 1, 2
- Fluid restriction is generally not necessary unless serum sodium is <120-125 mmol/L 1, 2
Diuretic Therapy
- Begin with spironolactone 100 mg once daily and furosemide 40 mg once daily 1, 2
- Spironolactone acts as an aldosterone antagonist, increasing sodium and water excretion while retaining potassium 4
- Furosemide enhances diuresis but should be used cautiously in patients with cirrhosis as sudden alterations in fluid and electrolyte balance may precipitate hepatic coma 5
- Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide 1, 2
Monitoring Response
- Measure urinary sodium excretion if weight loss is less than desired 1
- A 24-hour urinary sodium excretion >78 mmol/day indicates adequate response 1
- A random "spot" urine sodium concentration greater than potassium concentration correlates with 24-hour sodium excretion >78 mmol/day with approximately 90% accuracy 1
- Monitor serum electrolytes, creatinine, and weight regularly 2
Management of Underlying Cause
- In alcohol-induced liver disease, cessation of alcohol consumption is critical 1, 6, 2
- Patients with Child-Pugh class C cirrhosis who stop drinking have approximately 75% 3-year survival, compared to 0% in those who continue drinking 1, 6, 2
- For decompensated hepatitis B cirrhosis, antiviral treatment can lead to dramatic improvement 1
- For less reversible liver diseases, consider referral for liver transplantation evaluation 1, 2
Management of Tense Ascites
- For patients with tense, uncomfortable ascites, perform large-volume paracentesis (LVP) for rapid relief 1, 2
- Administer intravenous albumin (8g/L of fluid removed) after LVP to prevent circulatory dysfunction 2
- Resume diuretic therapy after paracentesis to prevent rapid reaccumulation 2, 7
Important Considerations and Pitfalls
- Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion and convert diuretic-sensitive patients to refractory 2
- Avoid medications that worsen hypotension, such as angiotensin-converting enzyme inhibitors 2
- Be aware that some patients may have multiple causes of ascites ("mixed ascites"), requiring treatment of all underlying conditions 1, 2
- The development of ascites indicates a poor prognosis, with approximately 20% of patients dying within the first year of diagnosis 2, 8