What is the initial management of acute ascites?

Initial Management of Acute Ascites

Perform an immediate diagnostic paracentesis in all patients with new-onset ascites, followed by ascitic fluid analysis including cell count with differential, total protein, and serum-ascites albumin gradient (SAAG) calculation. 1, 2

Immediate Diagnostic Workup

Mandatory Paracentesis

• Diagnostic paracentesis must be performed without delay in all patients presenting with new-onset grade 2 or 3 ascites (detectable on physical examination), regardless of coagulopathy or thrombocytopenia, as serious bleeding complications occur in less than 1 in 1,000 procedures. 1, 2
• Ultrasound guidance should be considered when available to reduce adverse events. 1
• Ascitic fluid should be inoculated into blood culture bottles at the bedside before any antibiotics are given. 1

Essential Ascitic Fluid Analysis

• Neutrophil count >250 cells/mm³ indicates spontaneous bacterial peritonitis (SBP) and requires immediate empirical antibiotic therapy with third-generation cephalosporins such as cefotaxime, guided by local resistance patterns. 1
• SAAG ≥1.1 g/dL indicates portal hypertension with 97% accuracy, which determines treatment approach—high SAAG ascites responds to salt restriction and diuretics, while low SAAG ascites typically does not. 1, 2
• Total protein concentration helps differentiate causes and assess infection risk. 1

Concurrent Laboratory Assessment

• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) to assess hepatic synthetic function. 2
• Renal function tests (creatinine, BUN) to identify hepatorenal syndrome. 2
• Serum albumin to calculate SAAG. 1
• Complete blood count and prothrombin time/INR. 2

Initial Therapeutic Management for Cirrhotic Ascites

For First-Episode Moderate Ascites (High SAAG ≥1.1 g/dL)

• Initiate spironolactone monotherapy at 100 mg daily, titrating up to 400 mg daily as first-line treatment. 1
• Implement moderate dietary sodium restriction to 5-6.5 g salt daily (87-113 mmol sodium), which translates to a no-added-salt diet with avoidance of precooked meals. 1
• Provide nutritional counseling on sodium content. 1

For Recurrent or Severe Ascites

• Use combination diuretic therapy with spironolactone (100-400 mg daily) plus furosemide (40-160 mg daily) when faster diuresis is needed or in hospitalized patients. 1
• The FDA label for furosemide warns that therapy in patients with hepatic cirrhosis and ascites is best initiated in the hospital, as sudden alterations in fluid and electrolyte balance may precipitate hepatic coma. 3

For Large Volume or Tense Ascites

• Perform therapeutic large-volume paracentesis (LVP) as first-line treatment, removing fluid in a single session. 1
• Administer albumin at 8 g per liter of ascites removed when >5 liters are drained to prevent post-paracentesis circulatory dysfunction. 1
• For paracentesis <5 liters, albumin can be considered in patients with acute-on-chronic liver failure or high risk of acute kidney injury. 1

Critical Management Considerations

Monitoring During Diuretic Therapy

• Almost half of patients on diuretics develop adverse events requiring dose reduction or discontinuation. 1
• Monitor serum electrolytes closely—hypovolemic hyponatremia requires diuretic discontinuation and plasma volume expansion with normal saline. 1
• Fluid restriction to 1-1.5 L/day should only be used in clinically hypervolemic patients with severe hyponatremia (serum sodium <125 mmol/L). 1

Spontaneous Bacterial Peritonitis Management

• If neutrophil count >250 cells/mm³, start empirical antibiotics immediately (cefotaxime most extensively studied, but choice should be guided by local resistance patterns and whether infection is community-acquired or healthcare-associated). 1
• In patients with SBP and elevated or rising serum creatinine, administer albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 to prevent hepatorenal syndrome. 1

Prognostic Implications

• The development of ascites represents hepatic decompensation and drops 5-year survival from 80% (compensated cirrhosis) to 30%, making this an indication for liver transplantation evaluation. 2
• All patients with new-onset ascites should be considered for transplant referral. 1

Common Pitfalls to Avoid

• Never withhold paracentesis due to coagulopathy or thrombocytopenia—routine measurement of PT/INR and platelet count before paracentesis and prophylactic transfusion of blood products are not recommended. 1
• Do not test serum CA125 in patients with ascites, as it is elevated in all patients with ascites of any cause (including men) and leads to unnecessary referrals and interventions. 1
• Do not restrict fluids routinely—fluid restriction is only indicated in severe hyponatremia (<125 mmol/L) with clinical hypervolemia. 1
• Bed rest is not recommended for treatment of ascites. 1