What is the most appropriate management for a patient with liver cirrhosis (Liver Cirrhosis) presenting with tense ascites (fluid accumulation in the abdomen) and lower limb edema (swelling due to fluid retention)?

Management of Tense Ascites in Cirrhosis

For a 55-year-old man with liver cirrhosis presenting with tense ascites, decreased level of consciousness, and lower limb edema, large volume paracentesis (LVP) followed by diuretic therapy is the most appropriate initial management.

Initial Management

• Large volume paracentesis is the first-line treatment for tense ascites (grade 3 ascites) as it rapidly relieves symptoms and improves patient comfort 1
• A single large-volume paracentesis followed by diet and diuretic therapy is appropriate treatment for patients with tense ascites 1
• LVP combined with hyper-oncotic human albumin is the initial treatment of choice, even in the presence of hyponatremia 1

Albumin Administration

• Albumin (20% or 25% solution) should be infused after paracentesis of >5L at a dose of 8g albumin/L of ascites removed to prevent circulatory dysfunction 1
• A prospective study demonstrated that a single 5-L paracentesis can be performed safely without post-paracentesis colloid infusion in patients with diuretic-resistant tense ascites 1
• For larger volumes, albumin administration is essential to prevent impairment of systemic hemodynamics and renal function 2

Follow-up Diuretic Therapy

• After paracentesis and significant reduction in intra-abdominal pressure, diuretics should be instituted to eliminate or reduce the frequency of subsequent paracentesis 1
• For recurrent severe ascites, combination therapy with spironolactone (starting dose 100 mg, increased to 400 mg) and furosemide (starting dose 40 mg, increased to 160 mg) is recommended 1
• Spironolactone has been shown to be more effective than furosemide alone in the elimination of ascites in cirrhotic patients 3

Monitoring and Precautions

• Regular monitoring of blood pressure, serum electrolytes, creatinine, and weight is necessary to guide therapy adjustments 4
• Avoid medications that worsen hypotension, such as ACE inhibitors, which can aggravate hypotension in cirrhotic patients 4
• In patients with cirrhosis and ascites, furosemide therapy should be initiated in the hospital setting, as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 5

Management of Refractory Cases

• For patients with refractory ascites (unresponsive to sodium-restricted diet and high-dose diuretic treatment), options include serial therapeutic paracenteses, liver transplantation, or transjugular intrahepatic portosystemic shunt (TIPS) 1
• TIPS should be considered in patients with refractory ascites, though caution is required in patients with hepatic encephalopathy, active infection, or elevated MELD scores 1

Pitfalls to Avoid

• Avoid thiazide diuretics alone as they can cause rapid development of hyponatremia when added to the combination of spironolactone and furosemide 1
• Prostaglandin inhibitors such as NSAIDs should be avoided as they can reduce urinary sodium excretion and convert patients from diuretic-sensitive to refractory 1
• Avoid rapid correction of serum sodium in patients with hyponatremia as it may lead to central pontine myelinolysis 1

Based on the most recent and highest quality evidence, the answer to the MCQ is option A (Large volume paracentesis) as the most appropriate initial management for this patient with tense ascites, followed by combination diuretic therapy.