What is the management approach for a patient presenting with ascites?

Management of Ascites in Cirrhosis

All patients presenting with new-onset or worsening ascites require immediate diagnostic paracentesis to determine the cause and rule out spontaneous bacterial peritonitis, followed by a structured treatment approach based on ascites severity. 1

Initial Diagnostic Evaluation

Perform diagnostic paracentesis in all patients with:

• New-onset grade 2 or 3 ascites 1
• Hospital admission with ascites 1
• Any signs of infection (fever, abdominal pain, encephalopathy) 1
• Worsening liver or renal function 1
• GI bleeding or shock 1

Essential ascitic fluid analysis includes:

• Serum-ascites albumin gradient (SAAG) - if ≥1.1 g/dL, confirms portal hypertension with 97% accuracy 1
• Neutrophil count - >250 cells/mm³ indicates spontaneous bacterial peritonitis 1
• Total protein concentration - <1.5 g/dL identifies high-risk patients requiring SBP prophylaxis 1
• Bedside inoculation of blood culture bottles (10 mL) 1

Additional tests (cytology, amylase, BNP, adenosine deaminase) should only be ordered when specific non-cirrhotic causes are suspected. 1

Treatment Algorithm Based on Ascites Severity

Grade 1 (Mild) Ascites

Start with conservative management:

• Sodium restriction to 5-6.5 g/day (87-113 mmol/day) - this means no added salt and avoiding precooked meals 1
• Spironolactone monotherapy starting at 100 mg daily, titrating up to 400 mg daily 1
• Monitor weight, electrolytes, and renal function every 3-5 days initially 1

Grade 2-3 (Moderate to Severe) Ascites

For first presentation with moderate ascites:

• Spironolactone 100 mg daily alone is reasonable 1
• Add furosemide 40 mg daily if faster response needed 1

For recurrent severe ascites or hospitalized patients:

• Combination therapy is recommended: spironolactone 100 mg plus furosemide 40 mg daily, maintaining a 100:40 mg ratio 1
• Increase both drugs simultaneously every 3-5 days if inadequate response 1
• Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1, 2

Target weight loss:

• 0.5 kg/day in patients without peripheral edema 3, 4
• Up to 1 kg/day if peripheral edema present 3

Tense Ascites

Large-volume paracentesis is first-line treatment:

• Provides immediate symptom relief within minutes 3
• For paracentesis <5 liters: use synthetic plasma expander (150-200 mL gelofusine or haemaccel) 1
• For paracentesis ≥5 liters: administer albumin 8 g per liter of ascites removed (approximately 100 mL of 20% albumin per 3 liters removed) to prevent post-paracentesis circulatory dysfunction 1, 3
• Follow with sodium restriction and diuretics to prevent reaccumulation 3, 4

Refractory Ascites Management

Refractory ascites is defined as: fluid overload unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg) with sodium restriction, or ascites that recurs rapidly after therapeutic paracentesis. 3, 5

Treatment options in order of preference:

1. Serial large-volume paracentesis every 2-3 weeks with albumin replacement (8 g/L removed) 3, 6
2. TIPS placement in selected patients - improves renal function and sodium excretion but requires careful patient selection due to risk of hepatic encephalopathy 1, 7
3. Liver transplantation evaluation - should be considered for all patients with refractory ascites 1, 7

Critical Monitoring Parameters

Monitor closely for diuretic complications:

• Hyponatremia: if serum sodium 121-125 mmol/L with elevated creatinine (>150 mmol/L), stop diuretics and give volume expansion 1
• Severe hyponatremia: if serum sodium <120 mmol/L, stop diuretics and consider volume expansion, but avoid increasing sodium by >12 mmol/L per 24 hours 1
• Hyperkalemia: spironolactone can cause dangerous potassium elevation, especially with ACE inhibitors, ARBs, or potassium supplements 2
• Hepatic encephalopathy and renal impairment 1, 2

Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L. 1, 3

Spontaneous Bacterial Peritonitis Management

If neutrophil count >250 cells/mm³:

• Start immediate empirical antibiotics - cefotaxime is most studied, but choice should be guided by local resistance patterns and whether infection is community-acquired or healthcare-associated 1
• Administer albumin 1.5 g/kg within first 6 hours, then 1 g/kg on day 3 to prevent renal impairment 1
• Consider repeat paracentesis at 48 hours if inadequate response 1

Secondary prophylaxis after SBP episode:

• Norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole (800/160 mg daily) 1

Primary prophylaxis for high-risk patients:

• Ascitic protein <1.5 g/dL warrants prophylactic antibiotics, but choice should be guided by local resistance patterns 1
• Patients with GI bleeding and ascites require prophylactic antibiotics to prevent SBP 1

Critical Pitfalls to Avoid

Absolute contraindications:

• NSAIDs must be strictly avoided - they reduce diuretic efficacy, decrease urinary sodium excretion, and can induce azotemia, converting diuretic-sensitive patients to refractory 8, 3, 2
• Avoid serial paracenteses without diuretic therapy in diuretic-sensitive patients 3

Special considerations:

• In patients with hepatic cirrhosis and ascites, initiate spironolactone in the hospital setting due to risk of sudden electrolyte imbalances precipitating hepatic encephalopathy 2
• Start with lowest doses and titrate slowly in cirrhotic patients as drug clearance is reduced 2
• Food increases spironolactone bioavailability by 95%, so establish a consistent pattern of taking medication with or without meals 2

Liver Transplantation Referral

The development of ascites marks hepatic decompensation and significantly worsens prognosis - 85% one-year survival and only 56% five-year survival without transplantation. 1, 7, 6 All patients with ascites should be evaluated for liver transplantation, preferably before development of renal dysfunction. 1, 7