What is the initial management for ascites due to liver cirrhosis?

Initial Management of Ascites Due to Liver Cirrhosis

Start with dietary sodium restriction to 88 mmol/day (2 g/day or approximately 5 g salt/day) combined with oral spironolactone 100 mg daily, adding furosemide 40 mg daily if needed, while avoiding NSAIDs entirely. 1, 2

Immediate Assessment and Diagnostic Workup

• Perform diagnostic paracentesis on all cirrhotic patients with new-onset ascites or hospital admission to measure serum-ascites albumin gradient (SAAG) and ascitic fluid neutrophil count 1
• Inoculate ascitic fluid into blood culture bottles at the bedside to detect spontaneous bacterial peritonitis 1
• Refer all patients with Grade 2 or 3 ascites for liver transplantation evaluation, as development of ascites indicates 50% mortality at 6 months for refractory cases 2

First-Line Treatment Strategy

For Tense Ascites (Severe, Symptomatic)

• Perform therapeutic large-volume paracentesis (LVP) first to provide rapid symptom relief within minutes 1, 2, 3
• Administer 8 g albumin intravenously per liter of ascites removed if >5 L is drained to prevent post-paracentesis circulatory dysfunction 1, 2, 3
• Immediately initiate sodium restriction and oral diuretics after paracentesis 1, 2, 3

For Mild to Moderate Ascites

• Begin with dietary sodium restriction to 88 mmol/day (2 g sodium or 5 g salt daily), which corresponds to a "no added salt" diet 1, 2
• Do NOT restrict sodium more severely as this worsens malnutrition already present in cirrhotic patients 2
• Start spironolactone 100 mg once daily as first-line diuretic, as it directly antagonizes aldosterone which drives sodium retention in cirrhosis 1, 2
• Add furosemide 40 mg once daily if spironolactone alone is insufficient, maintaining approximately a 100:40 mg ratio 1, 2

Diuretic Titration Protocol

• Increase both diuretics simultaneously every 3-5 days until achieving adequate natriuresis and weight loss 2
• Maximum doses are spironolactone 400 mg/day and furosemide 160 mg/day 1, 2
• Target weight loss of 0.5 kg/day in patients with ascites alone 2
• Target weight loss of 1 kg/day in patients with both ascites and peripheral edema 2

Monitoring Requirements

• Check body weight, serum sodium, serum potassium, and serum creatinine every 3-5 days initially when titrating diuretics 2
• Measure 24-hour urinary sodium excretion if weight loss is inadequate despite diuretics 2
• Monitor for diuretic complications including hepatic encephalopathy, renal impairment (creatinine >2.0 mg/dL), severe hyponatremia (<120 mmol/L), or hyperkalemia (>6.0 mmol/L) 1

Fluid Restriction Guidelines

Fluid restriction is NOT necessary in most patients with cirrhotic ascites. 1

• Reserve fluid restriction to 1-1.5 L/day only for patients with severe hyponatremia (serum sodium <120-125 mmol/L) 1, 2
• The chronic hyponatremia in cirrhotic ascites is seldom morbid and attempts to rapidly correct it can cause more complications than the hyponatremia itself 1

Critical Medications to Absolutely Avoid

• NSAIDs must be strictly avoided as they reduce urinary sodium excretion, induce azotemia, and convert diuretic-sensitive ascites to refractory ascites 1, 2, 3
• Avoid ACE inhibitors and angiotensin receptor blockers in patients with cirrhosis and ascites 2
• Avoid aminoglycoside antibiotics whenever possible due to nephrotoxicity risk 2

Treatment of Underlying Liver Disease

• Ensure complete alcohol abstinence in patients with alcoholic liver disease, as this can lead to dramatic improvement with approximately 75% 3-year survival in Child-Pugh C patients who stop drinking versus 0% survival in those who continue 1, 2
• Treat viral hepatitis with antivirals (HBV) or direct-acting antivirals (HCV) to improve liver function and reduce ascites 2

Nutritional Support

• Ensure adequate nutrition with 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day total calories 2
• Bed rest is NOT recommended for treatment of ascites 1

Common Pitfalls to Avoid

The 2021 Gut guidelines emphasize that routine measurement of prothrombin time and platelet count before paracentesis is not recommended, and infusion of blood products is unnecessary 1. This represents an important shift from older, more conservative practices.

When hyponatremia develops (sodium 126-135 mmol/L with normal creatinine), continue diuretic therapy but observe electrolytes closely—do not water restrict 1. For sodium 121-125 mmol/L with elevated creatinine (>150 mmol/L), stop diuretics and give volume expansion 1.

Avoid serial paracenteses without diuretic therapy in diuretic-sensitive patients, as this does not address the underlying sodium retention 3. The 2006 Gut guidelines note that fewer than 10% of patients with cirrhosis and ascites are truly refractory to standard medical therapy 1, so ensure adequate trial of dietary restriction and diuretics before labeling ascites as refractory.