What is the best management approach for a patient with ascites, particularly those with a history of liver disease?

Management of Ascites in Cirrhosis

First-line treatment consists of sodium restriction (88 mmol/day or 2000 mg/day) combined with oral spironolactone 100 mg daily, with furosemide added if needed, while patients with tense ascites should undergo initial therapeutic paracentesis followed by diuretic therapy. 1

Initial Assessment and Diagnostic Paracentesis

• Perform diagnostic paracentesis in all patients with new-onset ascites to determine the serum-ascites albumin gradient (SAAG) and rule out spontaneous bacterial peritonitis (SBP). 1
• Inoculate ascitic fluid into blood culture bottles at bedside and examine for neutrophil count. 1
• Measure ascitic protein concentration, as levels <15 g/L increase SBP risk and may warrant prophylaxis. 1

Management Algorithm Based on Ascites Severity

Moderate Ascites (First Presentation)

Start with spironolactone monotherapy 100 mg daily, increasing every 3-5 days up to 400 mg/day based on response. 1

• If suboptimal response (defined as <0.5 kg weight loss/day without edema or <1 kg/day with edema), add furosemide 40 mg daily, increasing up to 160 mg/day. 1
• The 2021 Gut guidelines recommend starting with spironolactone alone for first-line therapy, which differs from older approaches that used combination therapy upfront. 1
• Monitor spot urine sodium:potassium ratio (target 1.8-2.5) to predict adequate 24-hour urinary sodium excretion of >78 mmol/day. 1

Tense or Large-Volume Ascites

Perform initial therapeutic paracentesis to rapidly relieve symptoms, followed by sodium restriction and diuretics. 1

• For paracentesis <5 liters: use synthetic plasma expanders (150-200 mL gelofusine or haemaccel) without albumin. 1
• For paracentesis ≥5 liters: administer intravenous albumin at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction. 1
• Large-volume paracentesis removes fluid in minutes versus days-to-weeks with diuretics alone, but does not address underlying sodium retention. 1

Recurrent Moderate-to-Severe Ascites

Start combination therapy with spironolactone 100 mg plus furosemide 40 mg daily from the outset, titrating both upward simultaneously to maximum doses of 400 mg and 160 mg respectively. 1

Sodium and Fluid Restriction

• Restrict dietary sodium to 88 mmol/day (approximately 5-6.5 g salt/day or 2000 mg sodium/day). 1
• Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L. 1
• This is a critical point: sodium restriction, not fluid restriction, drives weight loss as fluid passively follows sodium. 1

Monitoring and Diuretic Adjustments

• Titrate diuretics every 3-5 days until achieving adequate natriuresis and weight loss. 1
• Target weight loss: 0.5 kg/day without peripheral edema; 1 kg/day with edema. 1, 2
• Monitor electrolytes, creatinine, and clinical status every 2-4 weeks initially until stable response achieved. 1

Temporarily discontinue diuretics if any of the following develop: 1

• Serum sodium <125 mmol/L
• Serum creatinine >2.0 mg/dL or rising significantly
• Serum potassium >6.0 mmol/L
• Worsening hepatic encephalopathy
• Severe muscle cramps

Management of Hyponatremia

Mild Hyponatremia (126-135 mmol/L)

• Continue diuretics without fluid restriction and monitor closely. 1

Moderate Hyponatremia (121-125 mmol/L)

• If serum creatinine is normal: The 2006 Gut guidelines suggest a cautious approach of stopping diuretics, though international consensus supports continuation. 1
• If serum creatinine is elevated (>150 mmol/L or rising): Stop diuretics immediately and provide volume expansion. 1

Severe Hyponatremia (<120 mmol/L)

• Stop all diuretics immediately. 1
• Most patients should receive volume expansion with colloid (gelofusine, haemaccel) or normal saline, but avoid increasing serum sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis. 1
• Fluid restriction (1-1.5 L/day) should be reserved only for clinically hypervolemic patients with severe hyponatremia who are not on diuretics and have normal creatinine. 1

Refractory Ascites

Refractory ascites is defined as fluid overload unresponsive to maximum diuretic doses (400 mg spironolactone + 160 mg furosemide) with sodium restriction, or rapid recurrence after paracentesis. 1, 3

Treatment Options for Refractory Ascites:

1. Serial therapeutic paracentesis every 2 weeks with albumin replacement (8 g/L removed) is the initial treatment of choice. 1, 3

2. Transjugular intrahepatic portosystemic shunt (TIPS): Consider for patients requiring frequent paracentesis with relatively preserved liver function, though it improves quality of life without proven survival benefit. 1, 4, 3

3. Liver transplantation: This is the only definitive therapy and should be considered in all patients with ascites, particularly those with refractory ascites. 1, 4

Critical Medication Precautions

Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) entirely in patients with cirrhotic ascites. 1, 5

• NSAIDs reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory ascites. 1
• NSAIDs also cause water retention and impair renal response to diuretics. 6

Additional Considerations

• Alcohol abstinence is mandatory for patients with alcohol-related liver disease. 1
• Bed rest is not recommended for ascites treatment. 1
• Patients recovering from SBP should receive continuous prophylaxis with norfloxacin 400 mg daily or ciprofloxacin 500 mg daily. 1
• Development of ascites carries 50% 2-5 year survival without transplantation, making early transplant evaluation essential. 2, 7