What is the management plan for a patient with decompensated cirrhosis (DC) and portal hypertension complicated by ascites, potentially due to a history of liver disease from alcohol abuse, hepatitis, or non-alcoholic fatty liver disease (NAFLD)?

Management of Decompensated Cirrhosis with Portal Hypertension and Ascites

The cornerstone of management is immediate removal of the etiological factor (alcohol cessation, antiviral therapy for hepatitis B/C) combined with sodium restriction and spironolactone-based diuretic therapy, while performing diagnostic paracentesis to exclude spontaneous bacterial peritonitis. 1, 2

Immediate Etiological Treatment

Treating the underlying cause is the single most important intervention that reduces mortality and prevents further decompensation. 1, 3

• Alcohol-related cirrhosis: Complete and permanent cessation of alcohol is mandatory and may lead to "re-compensation" with improved outcomes 3, 4
• Hepatitis B: Initiate entecavir (1 mg daily for decompensated patients) or tenofovir monotherapy regardless of HBV DNA level 3, 4
• Hepatitis C: Direct-acting antivirals improve liver function and reduce portal hypertension 4
• Autoimmune hepatitis: Immunosuppressive therapy shows beneficial effects even in decompensated cirrhosis 4

Diagnostic Paracentesis - Mandatory First Step

Perform diagnostic paracentesis immediately in all patients with new onset grade 2-3 ascites or any hospitalization for cirrhosis complications. 1

• Inoculate at least 10 ml of ascitic fluid into blood culture bottles at bedside to enhance culture sensitivity 1
• Measure neutrophil count (>250 cells/µl indicates spontaneous bacterial peritonitis requiring immediate antibiotics) 1
• Assess total protein concentration (<1.5 g/dl indicates higher SBP risk) 1
• Calculate serum-ascites albumin gradient (SAAG) if cirrhosis diagnosis is uncertain 1

Ascites Management - Stepwise Approach

Grade 1 Ascites (Mild, detected only by ultrasound)

• Sodium restriction to 90 mmol/day (5.2 g salt/day) 2, 4
• Discontinue NSAIDs, ACE inhibitors, and angiotensin receptor blockers 4
• No diuretics needed at this stage 4

Grade 2 Ascites (Moderate, detectable on physical exam)

• Initiate spironolactone 50-100 mg daily, titrating up to maximum 400 mg daily 2, 4
• Add furosemide 20-40 mg daily (maximum 160 mg daily) if inadequate response to spironolactone alone 2, 4
• Target weight loss of 0.5 kg/day in patients without peripheral edema, or 1 kg/day in those with edema 2
• Continue sodium restriction to 90 mmol/day 2, 4
• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 2, 3

Grade 3 Ascites (Tense, causing respiratory compromise)

• Perform initial large-volume therapeutic paracentesis 4
• Administer albumin 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 2
• Follow with sodium restriction and diuretic therapy as above 4

Critical FDA Warning: In hepatic cirrhosis with ascites, furosemide therapy is best initiated in the hospital, as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma; strict observation is necessary during diuresis 5

Infection Prophylaxis

Antibiotic prophylaxis significantly reduces mortality by preventing spontaneous bacterial peritonitis and hepatorenal syndrome. 2, 3

• Norfloxacin 400 mg orally twice daily for patients with ascitic protein <1.5 g/dl or prior SBP 2, 3
• Ceftriaxone 1 g IV every 24 hours for up to 7 days in decompensated cirrhosis with GI bleeding or quinolone-resistant settings 2, 3
• Important caveat: Long-term antibiotic prophylaxis increases risk of multidrug-resistant organisms; reserve for highest-risk patients only 1, 6

Portal Hypertension Management

Variceal Screening and Prevention

• Perform esophagogastroduodenoscopy (EGD) to screen for varices in all newly decompensated patients 1
• Non-selective beta-blockers (propranolol or carvedilol) prevent first variceal bleeding and reduce risk of ascites, hepatorenal syndrome, and SBP beyond variceal prevention alone 3, 7
• Endoscopic band ligation is equally effective as beta-blockers for primary prophylaxis of high-risk varices 1

Acute Variceal Bleeding Management

• Initiate vasoactive drugs immediately upon suspicion, even before endoscopic confirmation 3, 4
• Mandatory antibiotic prophylaxis with ceftriaxone 1 g/24h for up to 7 days 3, 4
• Perform endoscopic band ligation within 12 hours once hemodynamically stable 4
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dl, target 7-9 g/dl 4

Refractory Ascites Management

Ascites recurring at least three times within 12 months despite adequate sodium restriction and maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily) is defined as refractory. 1

• Serial large-volume paracentesis with albumin replacement (8 g/L removed) every 2-4 weeks 2, 4
• Transjugular intrahepatic portosystemic shunt (TIPS) in highly selected patients reduces further decompensation and improves survival 8, 9
• TIPS is particularly effective for preventing recurrent ascites and variceal rebleeding in patients with preserved liver function 8
• Immediate liver transplant evaluation - refractory ascites itself is an indication for transplant assessment 2, 4

Emerging Therapies Requiring Validation

• Statins: Show promise in reducing portal hypertension and improving survival through pleiotropic effects, but require validation before routine use 2, 3
• Long-term albumin infusion: Conflicting evidence from recent trials; further studies needed to determine efficacy and optimal dosing 1
• Rifaximin: May reduce complications beyond hepatic encephalopathy, but prospective data lacking for routine use in ascites management 1, 2
• Enoxaparin: 12-month course was safe and effective in preventing portal vein thrombosis in small trial, but requires further validation 1, 2

Critical Medications to Avoid

NSAIDs are absolutely contraindicated - they reduce urinary sodium excretion, precipitate renal failure, and convert diuretic-sensitive to refractory ascites 2, 4

• Discontinue ACE inhibitors and angiotensin receptor blockers 4
• Avoid all nephrotoxic agents 4
• Avoid excessive bed rest - causes muscle atrophy and worsens sarcopenia 4

Monitoring and Follow-up

• Monitor weight daily at home using Bluetooth-linked scales with smartphone apps for early intervention 4
• Check serum electrolytes, creatinine, and liver function regularly during diuresis 5
• Screen for hepatocellular carcinoma with ultrasound and AFP every 6 months 4
• Assess for sarcopenia using CT scan, handgrip strength, or short physical performance battery 4
• Early gastroenterology referral for any decompensation event, refractory ascites, or transplant evaluation 4

Nutritional Management

• Sodium restriction to 90 mmol/day (5.2 g salt/day) - more restrictive diets worsen malnutrition 4
• Perform rapid nutritional screening assuming high malnutrition risk if BMI <18.5 kg/m² or Child-Pugh C 4
• Adequate protein intake to prevent sarcopenia - protein restriction is outdated and harmful 4

Prognosis and Transplant Timing

Five-year survival drops from 80% in compensated cirrhosis to 30% with decompensated cirrhosis and ascites - this underscores the urgency of early transplant evaluation 1

• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation 3
• Patients requiring paracentesis more frequently than every 2 weeks likely have poor dietary compliance and need re-education 4
• Consider palliative care referral for non-transplant candidates with refractory ascites 4