What is the next line of treatment for a patient with a history of non-alcoholic cirrhosis and ascites, without hematemesis or melena?

Management of Ascites in Non-Alcoholic Cirrhosis

For a patient with non-alcoholic cirrhosis presenting with abdominal swelling due to ascites without hematemesis or melena, the first-line treatment in primary care should be sodium restriction (88 mmol/day or 2000 mg/day) and diuretic therapy with oral spironolactone starting at 100 mg daily, with or without oral furosemide.

Initial Assessment and Management

• Perform a diagnostic paracentesis to rule out spontaneous bacterial peritonitis and assess ascitic fluid characteristics 1
• Initial ascitic fluid analysis should include serum ascites-albumin gradient (SAAG) to confirm the cirrhotic origin of ascites 1
• Restrict dietary sodium to 88-90 mmol/day (2000 mg/day) - essentially a "no added salt" diet 2, 1, 3
• Bed rest is not recommended for treatment of ascites 1

Diuretic Therapy

• Begin with spironolactone 100 mg once daily as the initial diuretic 1, 4, 5

  • For patients with cirrhosis, the recommended initial daily dosage is 100 mg of spironolactone administered in either single or divided doses 4
  • Morning dosing maximizes compliance 2

• If response is inadequate after 3-5 days:

  • Add furosemide 40 mg once daily while maintaining spironolactone 1, 3
  • Maintain a spironolactone:furosemide ratio of 100 mg:40 mg to maintain normal potassium levels 1

• Doses can be increased simultaneously every 3-5 days if weight loss and natriuresis are inadequate 2, 1

  • Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide 2, 3

Monitoring and Follow-up

• Target weight loss of 0.5 kg/day in patients without peripheral edema and 1 kg/day in those with edema 1

• Monitor serum electrolytes, creatinine, and weight regularly 1, 6

• Watch for complications of diuretic therapy:

  • Hyponatremia (if serum sodium <120-125 mmol/L, fluid restriction may be necessary) 2, 1
  • Hyperkalemia (especially with spironolactone) 1, 4
  • Azotemia (elevated creatinine >2.0 mg/dL) 2
  • Hepatic encephalopathy 2

• Frequency of follow-up should be determined by response to treatment and patient stability, typically every 2-4 weeks initially 2

Management of Tense Ascites

• If the patient has tense ascites causing significant discomfort or respiratory compromise:
  • Perform therapeutic paracentesis to provide immediate symptom relief 2
  • For large-volume paracentesis (>5L), administer intravenous albumin (8g/L of ascites removed) to prevent circulatory dysfunction 2, 1
  • After paracentesis, continue sodium restriction and oral diuretics to prevent fluid reaccumulation 2, 7

Important Considerations and Precautions

• Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion and induce azotemia 2, 7, 8
• If gynecomastia develops with spironolactone, amiloride (10-40 mg/day) can be substituted, though it is less effective 2, 1
• Avoid hydrochlorothiazide as it can cause rapid development of hyponatremia when added to spironolactone and furosemide 2
• Consider liver transplantation evaluation for all patients with cirrhosis and ascites 2, 3, 9

Management of Refractory Ascites

• If ascites recurs rapidly or is unresponsive to maximum diuretic therapy (400 mg/day spironolactone and 160 mg/day furosemide), it is considered refractory 2
• Options for refractory ascites include:
  • Serial therapeutic paracenteses every 2-3 weeks 2
  • Transjugular intrahepatic portosystemic stent-shunt (TIPS) 2, 9
  • Liver transplantation 2, 3