How is ascites managed?

Management of Ascites in Cirrhosis

Start with dietary sodium restriction to 90 mmol/day (5.2 g salt/day) and spironolactone 100 mg daily as monotherapy, escalating to 400 mg/day before adding furosemide up to 160 mg/day if needed. 1, 2

Initial Diagnostic Evaluation

Perform diagnostic paracentesis on all cirrhotic patients with ascites at hospital admission to rule out spontaneous bacterial peritonitis and characterize the fluid. 1, 2 Key analyses include:

• Serum ascites-albumin gradient (SAAG) in preference to ascitic protein 1, 2
• Inoculate ascitic fluid into blood culture bottles at bedside and examine for neutrophil count 1, 2
• Ascitic amylase only when pancreatic disease is suspected 1

First-Line Medical Management

Sodium Restriction

Restrict dietary sodium to 90 mmol/day (5.2 g salt/day) - essentially a "no added salt" diet. 1, 2 Bed rest is not recommended and provides no benefit. 1

Diuretic Therapy Algorithm

For first presentation of moderate ascites:

• Begin with spironolactone 100 mg once daily as monotherapy 1, 2, 3
• Increase spironolactone by 100 mg every 7 days up to maximum 400 mg/day if inadequate response 1, 2
• Only add furosemide 40 mg daily if spironolactone 400 mg fails 1
• Increase furosemide up to 160 mg/day while maintaining spironolactone 1
• Maintain spironolactone:furosemide ratio of 100:40 mg to preserve normokalemia 2, 3

For recurrent moderate to severe ascites:

• Start combination therapy immediately: spironolactone 100 mg plus furosemide 40 mg daily 1, 2, 3
• Escalate both simultaneously every 3-5 days to maximum doses 1, 2, 3

Monitoring Diuretic Response

Target weight loss of 0.5 kg/day without peripheral edema, or 1 kg/day with edema present. 1, 2, 3 Monitor:

• Serum electrolytes (sodium, potassium) frequently 1, 2
• Serum creatinine for azotemia 1
• Spot urine sodium:potassium ratio to assess diuretic response (target 1.8-2.5) 1, 2

Management of Hyponatremia During Diuretic Therapy

Serum sodium 126-135 mmol/L with normal creatinine:

• Continue diuretics with close electrolyte monitoring 1
• Do not restrict water 1

Serum sodium 121-125 mmol/L with normal creatinine:

• Stop diuretics or adopt cautious approach (international opinion varies, but safer to stop) 1

Serum sodium 121-125 mmol/L with elevated creatinine (>150 μmol/L or >120 μmol/L and rising):

• Stop diuretics immediately and give volume expansion 1

Serum sodium <120 mmol/L:

• Stop diuretics and perform volume expansion with colloid (haemaccel, gelofusine, voluven) or saline 1
• Avoid increasing serum sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis 1
• Fluid restriction to 1-1.5 L/day only for severe hyponatremia (<125 mmol/L), though evidence is limited 1

Management of Large Volume or Tense Ascites

Therapeutic paracentesis is first-line treatment for large or refractory ascites rather than escalating diuretics. 1, 2

For paracentesis <5 liters:

• Use synthetic plasma expander (150-200 ml gelofusine or haemaccel) 1, 2
• Albumin not required for smaller volumes 1

For large volume paracentesis (≥5 liters):

• Administer albumin 8 g per liter of ascites removed (approximately 100 ml of 20% albumin per 3 liters removed) 1, 2
• Give volume expansion after paracentesis is complete 1
• Reinstitute diuretics within 1-2 days to prevent reaccumulation 1

Refractory Ascites

Defined as ascites unresponsive to maximum diuretic therapy (spironolactone 400 mg/day plus furosemide 160 mg/day) or rapid recurrence. 4, 5, 6 Treatment options:

• Serial large volume paracentesis with albumin replacement 1, 4, 5
• TIPS (transjugular intrahepatic portosystemic shunt) for appropriate candidates requiring frequent paracentesis 1, 5
• Liver transplantation evaluation - all patients with refractory ascites should be considered 1, 4, 5

Critical Pitfalls to Avoid

Overzealous diuresis causes:

• Intravascular volume depletion leading to renal impairment (25% of cases) 1
• Hepatic encephalopathy (26% of cases) 1
• Hyponatremia (28% of cases) 1

Never use furosemide as monotherapy - it is less effective than spironolactone and should not be used alone. 2, 7

Avoid NSAIDs - they reduce urinary sodium excretion, induce azotemia, and antagonize diuretic effects. 3, 8

Monitor for spironolactone-induced gynecomastia - substitute amiloride 10-40 mg/day if needed, though it is less effective. 2, 3

Ensure compliance with sodium restriction - if urinary sodium exceeds dietary intake despite diuretic resistance, assume non-compliance before declaring refractoriness. 1

Liver Transplantation Considerations

Development of ascites is an indication for transplantation evaluation as it marks hepatic decompensation and significantly worsens prognosis. 1, 4, 5, 9 Treatment of ascites improves quality of life and prevents complications like spontaneous bacterial peritonitis, but does not improve survival - only transplantation does. 1, 5, 9