What is the best management approach for a 60-year-old male with gross ascites, likely due to decompensated cirrhosis?

Management of Gross Ascites in a 60-Year-Old Male with Cirrhosis

For this patient with gross (grade 3) ascites, therapeutic large-volume paracentesis with albumin infusion is the first-line treatment, followed by initiation of spironolactone-based diuretic therapy and urgent evaluation for liver transplantation. 1

Immediate Management: Diagnostic and Therapeutic Paracentesis

Perform diagnostic paracentesis immediately on hospital admission to rule out spontaneous bacterial peritonitis (SBP) and characterize the ascites. 1 The ascitic fluid should be:

• Inoculated into blood culture bottles at the bedside 1
• Analyzed for cell count with differential (specifically neutrophil count) 1
• Tested for serum-ascites albumin gradient (SAAG) rather than total protein 1

Proceed immediately with large-volume paracentesis in a single session for gross ascites, as this provides rapid symptom relief with minimal complications and is superior to diuretics alone for tense ascites. 1, 2

Critical Albumin Replacement Protocol

Administer 8 grams of albumin per liter of ascites removed (approximately 100 ml of 20% albumin per 3 liters removed) once paracentesis is complete. 1 This prevents post-paracentesis circulatory dysfunction, which occurs in 20% of patients without albumin replacement and is associated with increased mortality. 3, 2, 4

Important caveat: For paracentesis <5 liters, synthetic plasma expanders (150-200 ml of gelofusine or haemaccel) may be used instead of albumin, though albumin is preferred for large-volume paracentesis. 1

Diuretic Therapy Initiation

Start spironolactone 100 mg daily as monotherapy after paracentesis, as this is the primary diuretic for cirrhotic ascites due to secondary hyperaldosteronism. 1 The FDA label specifically warns that furosemide therapy in hepatic cirrhosis with ascites is best initiated in the hospital under strict observation. 5

Stepwise Diuretic Algorithm

• Week 1-2: Spironolactone 100 mg daily, monitor weight loss (target 0.5 kg/day without peripheral edema, 1.0 kg/day with peripheral edema) 1, 6
• If inadequate response: Increase spironolactone to 200 mg, then 400 mg daily (maximum dose) 1
• If still inadequate: Add furosemide 40 mg daily, increasing to maximum 160 mg daily 1

Critical monitoring: Check serum sodium, potassium, and creatinine within 2-3 days of any dose change, then weekly during the first month. 1, 6

Dietary and Supportive Measures

Restrict dietary sodium to 90 mmol/day (5.2 g salt/day) with a no-added-salt diet. 1 More severe restriction is unnecessary and may worsen nutritional status. 1

Do NOT restrict water unless severe hyponatremia develops (see below). 1 Bed rest is not recommended and may worsen deconditioning. 1

Management of Complications

Hyponatremia Protocol

• Serum sodium 126-135 mmol/L: Continue diuretics, monitor closely, no water restriction 1
• Serum sodium 121-125 mmol/L with normal creatinine: Stop or reduce diuretics (controversial, but safer approach) 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 with colloid 1
• **Serum sodium <120 mmol/L**: Stop diuretics, give volume expansion with colloid or saline, but avoid increasing sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis 1

Refractory Ascites

If ascites persists despite maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily) or diuretics cannot be tolerated:

• Perform serial therapeutic paracenteses with albumin replacement 1
• Consider TIPS in appropriately selected patients with preserved liver function (ejection fraction >60%, not >50%) and frequent paracentesis requirements 1
• Expedite liver transplant evaluation immediately 1

Urgent Liver Transplant Referral

The development of ascites is an absolute indication for liver transplant evaluation, as it marks transition to decompensated cirrhosis with 50% two-year mortality. 1, 3 Treatment of ascites improves quality of life but does not significantly improve survival—only transplantation does. 1

Critical Pitfalls to Avoid

Never use IV furosemide as first-line therapy in cirrhotic patients, as it causes acute GFR reduction; oral route is strongly preferred. 6, 5 The FDA label explicitly warns that sudden alterations of fluid and electrolyte balance may precipitate hepatic coma, requiring strict observation during diuresis. 5

Never prescribe furosemide alone without spironolactone in cirrhotic ascites, as spironolactone addresses the primary pathophysiology (hyperaldosteronism). 6, 2

Never perform large-volume paracentesis without albumin replacement for volumes >5 liters, as this causes post-paracentesis circulatory dysfunction in 20% of cases with associated increased mortality. 3, 2, 4

Avoid NSAIDs completely, as they worsen renal function and sodium retention. 6

Infection Prophylaxis

If this patient develops SBP (ascitic fluid neutrophil count ≥250 cells/mm³):

• Start empiric third-generation cephalosporin (cefotaxime) immediately 1
• Give albumin 1.5 g/kg within 6 hours, then 1 g/kg on day 3 if signs of renal impairment 1
• Start lifelong SBP prophylaxis with norfloxacin 400 mg daily (or ciprofloxacin 500 mg daily) after recovery 1
• Expedite transplant evaluation immediately, as one-year mortality after SBP is 70% 1, 3