What is the initial management for a patient presenting with ascites, particularly in those with cirrhosis?

Initial Management of Ascites in Cirrhosis

First-line treatment consists of dietary sodium restriction to 5-6.5 g/day (87-113 mmol/day) combined with oral diuretics—spironolactone starting at 100 mg daily for moderate ascites, or combination spironolactone plus furosemide (starting at 100 mg and 40 mg respectively) for severe or recurrent ascites. 1

Immediate Assessment and Diagnostic Paracentesis

• Perform diagnostic paracentesis on all patients with new-onset ascites to rule out spontaneous bacterial peritonitis (SBP) and determine the serum-ascites albumin gradient (SAAG). 1
• Check ascitic fluid cell count with differential—neutrophil count >250/mm³ indicates SBP requiring immediate antibiotics. 1
• Inoculate blood culture bottles at bedside to maximize culture yield. 1
• SAAG ≥1.1 g/dL confirms portal hypertension as the cause with 97% accuracy. 2

Tense Ascites Requires Modified Approach

• If ascites is tense (causing respiratory compromise or severe discomfort), perform initial large-volume paracentesis to rapidly relieve symptoms. 1
• Administer intravenous albumin at 8 g per liter of ascites removed when removing >5 liters to prevent post-paracentesis circulatory dysfunction. 1, 2
• After therapeutic paracentesis, immediately initiate sodium restriction and oral diuretics to prevent reaccumulation. 1

Dietary Sodium Restriction

• Restrict sodium to 5-6.5 g salt per day (87-113 mmol sodium)—this translates to a no-added-salt diet with avoidance of precooked meals. 1
• Provide nutritional counseling specifically addressing sodium content in foods. 1
• Fluid restriction is NOT necessary unless serum sodium drops below 120-125 mmol/L. 1

Diuretic Therapy Algorithm

For First Presentation of Moderate Ascites:

• Start spironolactone monotherapy at 100 mg daily, titrating upward every 3-5 days to maximum 400 mg daily as needed to achieve weight loss and natriuresis. 1

For Recurrent/Severe Ascites or Hospitalized Patients:

• Use combination therapy from the start: spironolactone 100 mg plus furosemide 40 mg daily. 1
• Titrate both drugs upward together (spironolactone to 400 mg, furosemide to 160 mg) every 3-5 days until achieving adequate diuresis. 1
• This maintains the 100:40 mg ratio to prevent electrolyte disturbances. 1

Monitoring During Diuretic Therapy

• Monitor closely for adverse events—nearly half of patients require dose reduction or discontinuation. 1
• Target weight loss of 0.5 kg/day in patients without peripheral edema, or 1 kg/day in those with edema. 1
• Check electrolytes, renal function, and weight every 2-4 weeks initially until stable response confirmed. 1
• Measure urinary sodium excretion if not responding—goal is >78 mmol/day. 1

Critical Pitfalls to Avoid

• Avoid NSAIDs completely—they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive ascites to refractory ascites. 1
• Discontinue diuretics immediately if: 1
  • Serum creatinine rises >2.0 mg/dL
  • Serum sodium falls <120 mmol/L
  • Serum potassium rises >6.0 mmol/L
  • Hepatic encephalopathy worsens
• Do not use serial paracenteses as first-line therapy in diuretic-sensitive patients—this is inappropriate when diuretics can mobilize fluid. 1

Antibiotic Prophylaxis Considerations

• Initiate primary SBP prophylaxis if ascitic fluid protein <1.5 g/dL using norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole (800/160 mg daily), guided by local resistance patterns. 1
• If patient presents with GI bleeding, immediately start prophylactic antibiotics (cefotaxime widely studied, but choose based on local data) to prevent SBP. 1

Refractory Ascites Definition

Refractory ascites is diagnosed when: 1

• Ascites is unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg) with sodium restriction, OR
• Ascites recurs rapidly after therapeutic paracentesis, OR
• Diuretic-related complications develop preventing adequate dosing

Early Liver Transplant Referral

• Consider liver transplantation evaluation for all patients with cirrhosis and ascites—the development of ascites marks hepatic decompensation with significantly worsened prognosis (85% one-year survival, 56% five-year survival without transplant). 1, 3

Alcohol Cessation

• Patients with any alcohol component to their liver injury must abstain completely from alcohol consumption. 1