What is the initial management of new ascites?

Initial Management of New Ascites

Perform a diagnostic paracentesis immediately in all patients with new-onset grade 2 or 3 ascites, combined with ascitic fluid analysis including neutrophil count and serum-ascites albumin gradient (SAAG) calculation, followed by sodium restriction to 5-6.5g daily and initiation of spironolactone 100mg once daily. 1, 2

Mandatory Diagnostic Workup

Paracentesis - The Essential First Step

• Diagnostic paracentesis is non-negotiable for all patients with new-onset ascites and must be performed without delay 1, 2
• Do not withhold paracentesis due to coagulopathy or thrombocytopenia—serious bleeding complications occur in less than 1 in 1,000 procedures 1
• Inoculate ascitic fluid into blood culture bottles at the bedside to maximize bacterial detection 3, 2

Critical Ascitic Fluid Tests

• Neutrophil count: >250 cells/mm³ indicates spontaneous bacterial peritonitis (SBP) requiring immediate empirical antibiotics 1, 2
• SAAG calculation: A gradient ≥1.1 g/dL (or ≥11 g/L) indicates portal hypertension with 97% accuracy 1, 2
• Total protein concentration to further characterize the ascites 2

Concurrent Laboratory Assessment

• Liver function tests: AST, ALT, bilirubin, alkaline phosphatase 1
• Renal function: creatinine and BUN (critical for monitoring diuretic therapy) 1
• Prothrombin time/INR and complete blood count 1
• Serum albumin (required for SAAG calculation) 1, 2

Imaging

• Abdominal ultrasound to confirm ascites (at least 1,500 mL must be present before flank dullness is detectable on physical exam) and assess liver morphology 1

First-Line Treatment Algorithm

Step 1: Dietary Sodium Restriction

• Restrict sodium intake to 5-6.5g daily (87-113 mmol) 3, 2
• This is a no-added-salt diet, not severe restriction 3
• Adequate sodium restriction is essential—inadequate restriction limits diuretic effectiveness 2

Step 2: Initiate Spironolactone Monotherapy

• Start spironolactone 100mg once daily as first-line pharmacologic therapy 3, 2, 4
• Can increase up to 400mg daily if response is inadequate 3, 2
• Spironolactone acts as an aldosterone antagonist, directly targeting the pathophysiology of ascites in cirrhosis 4
• In cirrhotic patients, initiate therapy in the hospital setting due to risk of sudden fluid/electrolyte shifts that may precipitate hepatic encephalopathy 4, 5

Step 3: Add Furosemide if Needed

• If spironolactone alone fails to resolve ascites, add furosemide starting at 40mg daily 3, 2
• Can increase up to 160mg daily with careful monitoring 3, 2
• The combination targets both aldosterone-mediated sodium retention and loop diuretic mechanisms 3

Critical Monitoring Requirements

Electrolyte Management

• Monitor closely for hyponatremia and hyperkalemia—almost half of patients experience complications requiring dose adjustment 2
• For serum sodium 126-135 mmol/L with normal creatinine: continue diuretics but observe electrolytes closely; do not water restrict 3
• For serum sodium 121-125 mmol/L with normal creatinine: consider stopping or reducing diuretics 3
• For serum sodium 121-125 mmol/L with elevated creatinine (>150 mmol/L or >120 mmol/L and rising): stop diuretics and give volume expansion 3
• For serum sodium <120 mmol/L: stop diuretics and consider volume expansion with colloid or saline, but avoid increasing sodium by >12 mmol/L per 24 hours 3

Renal Function

• Monitor creatinine and BUN regularly, as spironolactone is substantially excreted by the kidney 4
• Patients with renal impairment are at increased risk of hyperkalemia 4

Management of Large or Tense Ascites

Large-Volume Paracentesis

• For removal of >5 liters, administer albumin at 8g per liter of ascites removed (approximately 100mL of 20% albumin per 3 liters removed) to prevent post-paracentesis circulatory dysfunction 3, 2
• For paracentesis <5 liters, synthetic plasma expanders (150-200mL of gelofusine or haemaccel) are sufficient 3
• Paracentesis can be performed in a single session with volume expansion given once complete 3

Transplant Evaluation - Non-Negotiable

All patients with new-onset ascites should be evaluated for liver transplantation 3, 2

• The development of ascites marks hepatic decompensation and dramatically worsens prognosis 1
• Five-year survival drops from 80% in compensated cirrhosis to 30% with ascites 1
• Treatment of ascites improves quality of life but does not significantly improve survival—transplantation is the definitive treatment 3

Common Pitfalls to Avoid

• Delaying diagnostic paracentesis: Each hour of delay increases hospital mortality by 3.3% 2
• Failing to screen for SBP: Always check neutrophil count in hospitalized cirrhotic patients with ascites 2
• Withholding paracentesis for coagulopathy: Bleeding risk is extremely low (<0.1%) 1
• Starting with combination diuretics: Begin with spironolactone monotherapy first 3, 2
• Inadequate sodium restriction: Limits effectiveness of all other therapies 2
• Not considering transplant evaluation: Ascites development is an absolute indication to discuss transplantation 3, 2
• Bed rest: Not recommended for treatment of ascites 3