What is the next step in managing a patient with ascites and effusion?

Management of Ascites and Pleural Effusion

Perform diagnostic paracentesis immediately to rule out spontaneous bacterial peritonitis (SBP), and if pleural effusion is present without ascites or when paracentesis has ruled out SBP but infection is still suspected, proceed with diagnostic thoracentesis. 1

Initial Diagnostic Workup

Diagnostic Paracentesis

• All patients with new-onset ascites or those admitted to hospital with known ascites must undergo diagnostic paracentesis, even without symptoms or signs of infection. 1
• Send ascitic fluid for:
  • Cell count with differential (specifically polymorphonuclear leukocyte count) 1
  • Total protein and albumin 1
  • Bedside inoculation of at least 10 mL into aerobic and anaerobic blood culture bottles before any antibiotics are given 1
  • Serum-ascites albumin gradient (SAAG) - calculated by subtracting ascitic fluid albumin from serum albumin 1

Interpretation of SAAG

• SAAG ≥1.1 g/dL indicates portal hypertension with 97% accuracy (typically cirrhosis-related ascites) 1
• SAAG <1.1 g/dL suggests non-portal hypertension causes (malignancy, tuberculosis, nephrotic syndrome) 1

Diagnostic Thoracentesis

• If pleural effusion is present and there is no ascites, or if diagnostic paracentesis has ruled out SBP but bacterial infection is still suspected, perform diagnostic thoracentesis. 1
• Note that pleural fluid analysis has limited diagnostic efficacy in cirrhotic patients, and clinical/radiologic data should guide diagnosis 2

Immediate Management Based on PMN Count

If PMN Count >250/mm³ (SBP/Spontaneous Bacterial Empyema)

• Start IV antibiotics empirically before culture results return 1
• First-line: IV cefotaxime 2g every 12 hours in community-acquired settings where multidrug-resistant organisms (MDROs) are not prevalent 1
• Consider broader coverage with carbapenems for:
  • Nosocomial infections 1
  • Recent hospitalization 1
  • Critically ill/ICU patients 1
• Do NOT place a chest tube for spontaneous bacterial empyema despite the term "empyema" 1
• Administer IV albumin 1.5 g/kg within first 6 hours, then 1g/kg on day 3 if signs of renal impairment develop 1

If PMN Count <250/mm³ (No Infection)

Proceed with treatment of ascites based on severity.

Treatment Algorithm for Ascites

For Tense Ascites

• Perform large-volume paracentesis (LVP) as first-line treatment - this provides rapid symptom relief within minutes 3
• For paracentesis <5L: administer synthetic plasma expander (150-200 mL gelofusine or haemaccel) 1, 3
• For paracentesis ≥5L: administer IV albumin 8g per liter of ascites removed (approximately 100 mL of 20% albumin per 3L removed) 1, 3
• Following paracentesis, immediately initiate sodium restriction and oral diuretics to prevent reaccumulation 3, 4

Sodium Restriction

• Restrict dietary sodium to 88 mmol/day (2000 mg/day) - essentially a "no added salt" diet 1, 3, 4
• This is approximately one teaspoon of salt total per day 1
• Fluid restriction is NOT necessary unless serum sodium <120-125 mmol/L 1, 3

Diuretic Therapy

Initial regimen:

• Start spironolactone 50-100 mg once daily (morning dosing preferred for compliance) 3, 4
• If inadequate response after 3-5 days, add furosemide 40 mg once daily while continuing spironolactone 3, 4
• Maintain spironolactone:furosemide ratio of 100:40 mg to preserve normal potassium levels 4

Dose titration:

• Increase both medications simultaneously every 3-5 days if weight loss and natriuresis are inadequate 3, 4
• Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 3, 4

Monitoring:

• Target weight loss: 0.5 kg/day without peripheral edema; 1 kg/day with edema 4
• Monitor serum electrolytes, creatinine, and weight within 1 week of initiation/titration, then regularly 4, 5
• Watch for complications: hyponatremia, hyperkalemia, azotemia, hepatic encephalopathy 4, 5

Critical Precautions

• Strictly avoid NSAIDs - they reduce diuretic efficacy, induce azotemia, and can convert diuretic-sensitive to refractory ascites 3, 4
• Monitor for hyperkalemia risk, especially with concomitant ACE inhibitors, ARBs, or potassium supplementation 5
• If gynecomastia develops with spironolactone (occurs in ~9% of males), substitute amiloride 10-40 mg/day, though it is less effective 4

Management of Refractory Ascites

Definition: Ascites unresponsive to maximum diuretic doses (spironolactone 400 mg/day + furosemide 160 mg/day) with sodium restriction, or ascites that recurs rapidly after therapeutic paracentesis 3, 4

Treatment options:

• Serial therapeutic paracenteses with albumin replacement (8g/L removed) 3, 4
• Transjugular intrahepatic portosystemic shunt (TIPS) in carefully selected patients - avoid in advanced liver disease or poor cardiac function 1, 4
• Liver transplantation evaluation - development of ascites indicates poor prognosis and is an indication for transplant consideration 1, 3

Common Pitfalls to Avoid

• Never perform serial paracenteses without initiating diuretic therapy in diuretic-sensitive patients - this fails to address underlying sodium retention 3
• Do not restrict fluids routinely - chronic hyponatremia in cirrhotic ascites is seldom morbid, and rapid correction with hypertonic saline causes more complications 1
• Avoid rapid sodium correction >12 mmol/L per 24 hours 1
• Do not delay diagnostic paracentesis - SBP carries high mortality and must be diagnosed/treated promptly 1
• Recognize that TIPS is contraindicated in patients with recurrent/refractory ascites and poor cardiac function due to risk of cardiac failure from increased preload 1

Special Considerations for Pleural Effusion Management

• In patients with tense ascites and acute kidney injury, perform diagnostic paracentesis first to exclude SBP as cause of AKI 1
• Pleural fluid analysis in cirrhotic patients has limited diagnostic value - rely more heavily on clinical and radiologic findings 2
• If primary pleural disease is suspected (tuberculosis, parapneumonic effusion), standard pleural fluid criteria may not reliably differentiate from hepatic hydrothorax 2