What is the most appropriate next step in managing a patient with liver cirrhosis, large ascites, and no signs of infection or altered mental status, who is already on spironolactone (aldosterone antagonist) and furosemide (loop diuretic)?

Management of Large Ascites in Cirrhosis on Diuretic Therapy

Therapeutic paracentesis is the most appropriate next step for this patient with large/tense ascites already on diuretic therapy. 1, 2

Rationale for Therapeutic Paracentesis

Patients with tense or large ascites should receive an initial therapeutic paracentesis to rapidly relieve symptoms, followed by optimization of sodium restriction and oral diuretics to prevent reaccumulation. 1, 2 This approach is superior to simply increasing diuretics because:

• Large-volume paracentesis removes fluid predictably within minutes, compared to careful diuresis which takes days to weeks 2
• Compared with diuretic treatment alone, therapeutic paracentesis with intravenous albumin replacement shortens hospital length of stay and reduces the risk of hyponatremia, acute kidney injury, and hepatic encephalopathy 3
• The patient already has "large ascites" causing significant fluid accumulation, which meets the indication for therapeutic paracentesis 3

Post-Paracentesis Management

After the paracentesis is performed:

• Infuse albumin at 6-8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 3, 2
• Following the initial paracentesis, maintenance diuretic therapy should be initiated or optimized to prevent fluid reaccumulation 2
• The diuretic regimen should be optimized by increasing spironolactone (up to 400 mg/day) and furosemide (up to 160 mg/day) while maintaining a 100:40 mg ratio to preserve normokalemia 3, 2
• Sodium intake should be restricted to 88 mmol/day (approximately 5 g salt/day or 2000 mg sodium/day) 3, 1

Why Other Options Are Incorrect

Intravenous diuretics (Option A): Not indicated as first-line therapy for large ascites; oral diuretics are already being used, and IV formulation offers no advantage for chronic management 4

Increase furosemide dose (Option C): Premature without first performing therapeutic paracentesis for symptomatic large ascites; diuretic optimization should occur after paracentesis 1, 2

TIPS (Option D): Reserved for refractory ascites, defined as fluid overload unresponsive to maximum diuretic doses (400 mg spironolactone + 160 mg furosemide) with sodium restriction, or rapid recurrence after paracentesis 3. This patient has not yet been optimized on maximum medical therapy or undergone therapeutic paracentesis.

Critical Monitoring Points

• Target weight loss after paracentesis and diuretic optimization: 0.5 kg/day without peripheral edema, or up to 1 kg/day with edema 1, 2
• Monitor closely for hepatic encephalopathy, hyponatremia, hyperkalemia, and acute kidney injury 2
• Avoid NSAIDs entirely, as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory ascites 1

Long-Term Considerations

Liver transplantation evaluation should be considered for all patients with cirrhotic ascites, as development of ascites represents hepatic decompensation with significantly worsened prognosis 2, 5