What is the best next step in management for a patient with HBV (Hepatitis B Virus) cirrhosis, ascites, and lower limb edema, who is already on a salt-restricted diet?

Management of HBV Cirrhosis with Moderate Ascites

The best next step in management is B: Furosemide and spironolactone combination therapy, as this patient presents with moderate ascites requiring hospitalization and has already been on salt restriction, making combination diuretic therapy the guideline-recommended first-line pharmacologic intervention. 1

Rationale for Combination Diuretic Therapy

This patient requires immediate diuretic initiation because:

• He has moderate ascites (Grade 2) with symptomatic fluid overload (increasing abdominal girth, lower limb edema, significant weight gain) that warrants hospitalization 1
• The 2021 Gut guidelines specifically recommend combination therapy with spironolactone (starting dose 100 mg, increased to 400 mg) and furosemide (starting dose 40 mg, increased to 160 mg) for patients with recurrent severe ascites or when faster diuresis is needed, particularly if the patient is hospitalized 1
• Salt restriction alone has already been implemented but is insufficient to control his ascites 1

Why Not the Other Options?

Large-volume paracentesis (Option C) is NOT indicated because:

• LVP is reserved for Grade 3 (large/tense) ascites or refractory ascites unresponsive to maximum diuretic therapy 1
• This patient has moderate ascites that should respond to diuretics as first-line therapy 1, 2
• Approximately 90% of patients with moderate ascites respond well to medical therapy with diuretics 3

TIPS (Option A) is NOT indicated because:

• TIPS is reserved for refractory ascites that repeatedly fails large-volume paracentesis and medical management 3
• This patient has not yet received any diuretic therapy, making TIPS premature 1

Terlipressin and albumin (Option D) is NOT indicated because:

• This combination is used for hepatorenal syndrome, not uncomplicated ascites 2
• The patient's creatinine and other parameters do not suggest hepatorenal syndrome at this time 1

Specific Diuretic Regimen

Initial dosing should be:

• Spironolactone 100 mg once daily PLUS furosemide 40 mg once daily 1, 4, 5
• This 100:40 ratio maintains adequate serum potassium levels while providing effective diuresis 1
• Maximum doses are spironolactone 400 mg/day and furosemide 160 mg/day 1, 3

Critical Monitoring Parameters

Close monitoring is essential because almost half of patients develop adverse events requiring dose adjustment: 1

• Target weight loss: 0.5 kg/day without peripheral edema; 1.0 kg/day with peripheral edema (this patient has edema, so 1 kg/day is acceptable) 1, 2
• Monitor serum electrolytes, creatinine, and body weight every 2-3 days initially 1, 2
• Watch for hepatic encephalopathy (occurs in up to 25% of hospitalized patients on diuretics), renal impairment (14-20%), and hyponatremia 1

Important Caveats

Common pitfalls to avoid:

• Do NOT use loop diuretics (furosemide) as monotherapy—spironolactone is far more effective (95% vs 52% response rate) in cirrhotic ascites 1, 6
• Do NOT restrict fluids unless severe hyponatremia (<125 mmol/L) develops with clinical hypervolemia 1, 2, 7
• Do NOT use intravenous diuretics routinely, as oral administration is standard and IV use can cause sudden fluid shifts leading to kidney damage 1, 5
• In patients with cirrhosis, diuretic therapy should be initiated in a hospital setting with slow titration 4, 5

Ascitic Fluid Analysis Considerations

While the neutrophil count is not provided in the question, the ascitic fluid analysis is important:

• If neutrophil count >250/μL, spontaneous bacterial peritonitis must be treated with empirical antibiotics (cefotaxime or based on local resistance patterns) before or concurrent with diuretic therapy 1
• The ascitic albumin level helps calculate the serum-ascites albumin gradient (SAAG) to confirm portal hypertension as the cause 8