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 before initiating any treatment to rule out spontaneous bacterial peritonitis and confirm the etiology. 1

Initial Diagnostic Evaluation

Perform diagnostic paracentesis in the following situations:

• All patients with new-onset grade 2 or 3 ascites 1
• All hospitalized patients with worsening ascites or any complication of cirrhosis 1
• Patients with GI bleeding, shock, fever, systemic inflammation, hepatic encephalopathy, or worsening liver/renal function 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 indicates high risk for SBP) 1
• Bedside inoculation of 10 mL into blood culture bottles 1
• Additional tests (cytology, amylase, BNP, adenosine deaminase) only if specific diagnoses suspected 1

Critical pitfall: Approximately 25% of ascites cases in Western populations are non-cirrhotic (malignancy, heart failure, tuberculosis, pancreatic disease), making diagnostic paracentesis essential before assuming cirrhotic etiology. 1

Treatment Algorithm Based on Ascites Severity

For First-Presentation Moderate Ascites (Grade 2)

Start with spironolactone monotherapy:

• Initial dose: 100 mg once daily 1
• Titrate upward every 3-5 days if inadequate response 1
• Maximum dose: 400 mg/day 1

Add furosemide only if spironolactone alone fails:

• Initial dose: 40 mg once daily 1
• Maintain 100:40 mg ratio of spironolactone to furosemide when increasing doses 2
• Maximum dose: 160 mg/day 1

For Recurrent or Severe Ascites (Grade 3/Tense Ascites)

Large-volume paracentesis is first-line treatment:

• Provides immediate symptom relief within minutes 3
• Can safely remove all ascitic fluid in a single session 1, 3
• Albumin replacement is mandatory for volumes >5 liters: 8 g albumin per liter of ascites removed 1, 3
• For paracentesis <5 liters, synthetic plasma expanders (150-200 mL gelofusine or haemaccel) are acceptable alternatives to albumin 1

After paracentesis, immediately initiate:

• Combination diuretic therapy: spironolactone 100 mg + furosemide 40 mg daily 1, 3
• Sodium restriction to 5-6.5 g/day (87-113 mmol sodium) - this means no added salt diet with avoidance of precooked meals 1

Important distinction: The 2021 Gut guidelines 1 recommend combination therapy from the start for hospitalized patients with severe ascites, while the 2006 guidelines 1 favored spironolactone monotherapy initially. The more recent approach prioritizes faster diuresis in acute settings.

Dietary and Lifestyle Management

Sodium restriction is essential:

• Limit to 5-6.5 g salt daily (87-113 mmol sodium) 1
• Provide nutritional counseling on sodium content 1
• Fluid restriction is NOT necessary unless serum sodium drops below 120-125 mmol/L 1, 3

Protein intake should be maintained:

• Target 1.2-1.5 g/kg/day to prevent malnutrition 4

Monitoring During Diuretic Therapy

Monitor closely for complications (occur in approximately 50% of patients):

• Weight, electrolytes, and renal function every 2-4 weeks initially 2, 4
• Target weight loss: 0.5 kg/day without peripheral edema, up to 1 kg/day with edema 3
• Stop diuretics immediately if: serum sodium <120-125 mmol/L with elevated creatinine (>150 μmol/L), or signs of hepatic encephalopathy develop 1

Critical medication interactions to avoid:

• NSAIDs are absolutely contraindicated - they reduce diuretic efficacy, induce azotemia, and can convert diuretic-sensitive to refractory ascites 2, 3, 5
• Avoid potassium supplements, salt substitutes, ACE inhibitors, ARBs (risk of severe hyperkalemia) 5
• Lithium clearance is reduced by spironolactone (toxicity risk) 5

Management of Refractory Ascites

Definition: Ascites unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily) with sodium restriction, or ascites that recurs rapidly after therapeutic paracentesis. 3, 6

Treatment options in order of preference:

1. Serial large-volume paracentesis every 2-3 weeks:

   • With albumin replacement (8 g/L removed) 1, 3
   • Safest option for most patients 7

2. Transjugular intrahepatic portosystemic shunt (TIPS):

   • More effective for long-term ascites control than repeated paracentesis 8, 9
   • However, may worsen hepatic function and cause chronic hepatic encephalopathy 9
   • Requires careful patient selection with appropriate risk-benefit assessment 1

3. Liver transplantation evaluation:

   • All patients with ascites should be considered for transplant referral 1, 8
   • Development of ascites indicates poor prognosis (85% 1-year survival, 56% 5-year survival without transplant) 7
   • Transplant should ideally occur before renal dysfunction develops 8

Management of Spontaneous Bacterial Peritonitis

If neutrophil count >250/mm³:

• Start empirical antibiotics immediately without waiting for culture results 1
• Cefotaxime is most extensively studied, but choice should be guided by local resistance patterns 1
• Consider healthcare-associated vs. community-acquired context when selecting antibiotics 1

Add albumin for patients with renal impairment:

• 1.5 g/kg within first 6 hours, then 1 g/kg on day 3 1
• This reduces mortality in SBP with renal dysfunction 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:

• Indicated when ascitic protein <1.5 g/dL 1
• Also indicated for patients with GI bleeding 1
• Antibiotic choice should be guided by local resistance patterns 1

Special Considerations for Hepatic Impairment

Patients with cirrhosis and ascites require hospital initiation of spironolactone:

• Risk of sudden fluid/electrolyte shifts precipitating hepatic encephalopathy and coma 5
• Start with lowest dose and titrate slowly 5
• Spironolactone half-life is prolonged in cirrhotic ascites 5

Key Pitfalls to Avoid

• Never perform serial paracenteses without diuretic therapy in diuretic-sensitive patients - this fails to address underlying sodium retention 3
• Never use NSAIDs in ascitic patients - they are contraindicated 2, 3, 5
• Never restrict fluids unless serum sodium <120-125 mmol/L 1, 3
• Never delay transplant evaluation - ascites development is an indication for referral 1, 8
• Never omit albumin replacement for large-volume paracentesis >5 liters - prevents post-paracentesis circulatory dysfunction 1, 3