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

Initial Management of Ascites in Cirrhosis

For patients presenting with new-onset ascites, begin with diagnostic paracentesis to confirm the diagnosis and rule out infection, followed immediately by moderate sodium restriction (2 g or 90 mmol/day) and diuretic therapy with spironolactone 100 mg daily as first-line treatment. 1

Diagnostic Evaluation

Perform diagnostic paracentesis in all patients with new-onset ascites to establish the diagnosis and exclude spontaneous bacterial peritonitis (SBP). 1 The essential laboratory tests on ascitic fluid include:

• Ascitic fluid neutrophil count (to detect SBP - treat if ≥250 cells/mm³) 1
• Ascitic fluid total protein and albumin 1
• Serum albumin to calculate serum-ascites albumin gradient (SAAG) - a SAAG ≥1.1 g/dL indicates portal hypertension with 97% accuracy 1, 2

First-Line Medical Management

Dietary Sodium Restriction

Prescribe moderate sodium restriction to 2 g (90 mmol) per day - this translates to a no-added-salt diet with avoidance of precooked meals. 1 This is the cornerstone of therapy and works synergistically with diuretics. 1

• Provide formal nutritional counseling on sodium content in foods to maximize adherence while avoiding malnutrition. 1
• Fluid restriction is NOT necessary unless severe hyponatremia (serum sodium <125 mmol/L) develops. 1

Diuretic Therapy

For first presentation of moderate ascites (Grade 2), initiate spironolactone monotherapy starting at 100 mg daily, which can be increased to 400 mg daily based on response. 1 This approach generates adequate response with fewer side effects in new-onset ascites. 1

For recurrent or severe ascites, or when faster diuresis is needed (hospitalized patients), use combination therapy from the start: spironolactone 100 mg plus furosemide 40 mg daily, titrating upward together (maximum spironolactone 400 mg, furosemide 160 mg). 1

The rationale: Spironolactone blocks aldosterone-mediated sodium retention in the distal tubule, while furosemide acts on the loop of Henle. 3 Patients with long-standing ascites respond better to combination therapy. 1

Monitoring During Diuretic Therapy

Monitor body weight daily - target weight loss should not exceed 0.5 kg/day in patients without peripheral edema (to avoid plasma volume contraction and renal failure), or 1 kg/day in those with edema. 1

Check serum electrolytes, creatinine, and sodium regularly, particularly during the first weeks of treatment. 1 Almost half of patients develop adverse events requiring dose adjustment or discontinuation. 1

Use spot urine sodium-to-potassium ratio to assess diuretic response when 24-hour urine collection is not feasible: if spot urine Na/K ratio >1, the patient should be losing weight; if not, suspect dietary noncompliance. If ratio ≤1, increase diuretics. 1

Management of Tense Ascites (Grade 3)

For patients with tense ascites, perform large-volume paracentesis (LVP) as initial treatment to rapidly relieve symptoms, even in the presence of hyponatremia. 1

• Administer albumin at 8 g per liter of ascites removed when removing >5 liters to prevent post-paracentesis circulatory dysfunction. 1, 2
• After LVP, initiate sodium restriction and diuretics to prevent reaccumulation. 1
• Ultrasound guidance should be considered when available to reduce adverse events. 1
• Routine coagulation testing and prophylactic blood product transfusion are NOT recommended before paracentesis. 1

Critical Pitfalls to Avoid

Do NOT restrict fluids unless severe hyponatremia (sodium <125 mmol/L) is present - this is a common error that does not help mobilize ascites. 1

Avoid NSAIDs - they reduce urinary sodium excretion, can induce azotemia, and convert diuretic-sensitive patients to refractory ascites. 1, 3

Monitor for diuretic complications: hyponatremia, hyperkalemia (especially with spironolactone), renal dysfunction, and hepatic encephalopathy. 1 Discontinue diuretics and expand plasma volume with normal saline if hypovolemic hyponatremia develops. 1

Titrate diuretics slowly - allow at least 72 hours between dose adjustments as spironolactone has a long half-life. 1, 3

Additional Considerations

Refer for liver transplantation evaluation in all patients with new-onset ascites, as this represents decompensated cirrhosis with significantly reduced survival (85% at 1 year, 56% at 5 years without transplant). 1, 4

Consider alcohol abstinence counseling if alcohol-related liver disease contributes to cirrhosis. 1

For painful gynecomastia from spironolactone, consider switching to amiloride or eplerenone. 1

For muscle cramps (common with diuretics), consider baclofen 10 mg daily, increasing by 10 mg weekly up to 30 mg daily, or albumin 20-40 g weekly. 1