What are the management options for a patient with alcoholic cirrhosis and ascites?

Management of Alcoholic Cirrhosis with Ascites

For alcoholic cirrhosis with ascites, initiate treatment with dietary sodium restriction to 5-6.5 g/day (2000 mg sodium) combined with spironolactone 100 mg daily, adding furosemide 40 mg daily if hospitalized or if faster diuresis is needed, while absolute alcohol abstinence is crucial for ascites control. 1, 2

Initial Assessment

• Perform diagnostic paracentesis in all patients with new-onset ascites to rule out spontaneous bacterial peritonitis (SBP) and confirm portal hypertension as the cause by measuring serum-ascites albumin gradient (SAAG ≥1.1 g/dL indicates portal hypertension). 1, 2

• Obtain informed consent before paracentesis and consider ultrasound guidance to reduce adverse events. 1

• Do NOT routinely check prothrombin time, platelet count, or transfuse blood products before paracentesis. 1

Dietary Management

Restrict dietary sodium to 5-6.5 g salt/day (87-113 mmol or 2000 mg sodium/day), which translates to a "no added salt" diet with avoidance of precooked meals. 1, 2

• Provide nutritional counseling on sodium content in foods. 1

• Do NOT restrict fluids unless serum sodium falls below 120-125 mmol/L. 1, 2

Diuretic Therapy Algorithm

For First Episode of Moderate Ascites (Outpatient):

• Start spironolactone 100 mg once daily as monotherapy. 1, 2
• Increase by 100 mg every 7 days up to maximum 400 mg/day if inadequate response. 1
• Add furosemide 40 mg daily only if spironolactone alone fails. 1

For Recurrent or Severe Ascites (Hospitalized Patients):

• Start combination therapy immediately: spironolactone 100 mg + furosemide 40 mg once daily in the morning. 1, 2
• Increase both drugs simultaneously every 3-5 days (maintaining 100:40 mg ratio) up to maximum doses of spironolactone 400 mg and furosemide 160 mg daily. 1
• This ratio maintains normokalemia and achieves faster natriuresis. 1

For Tense Ascites:

• Perform large volume paracentesis first to provide immediate symptom relief. 2, 3
• Administer albumin 8 g per liter of ascites removed (approximately 100 ml of 20% albumin per 3 liters removed) to prevent circulatory dysfunction. 1, 2
• For paracentesis <5 liters, synthetic plasma expanders (150-200 ml gelofusine or haemaccel) are acceptable alternatives. 1
• Follow with oral diuretics to prevent reaccumulation. 2, 3

Monitoring During Diuretic Therapy

• Target weight loss: 0.5 kg/day without peripheral edema; 1.0 kg/day with peripheral edema. 1, 2

• Monitor serum electrolytes, creatinine, and sodium frequently during the first weeks of treatment, as almost half of patients develop adverse events requiring dose adjustment or discontinuation. 1

Management of Complications

Hyponatremia:

• Serum sodium 125-130 mmol/L: Continue diuretics but monitor closely. 1
• Serum sodium 121-125 mmol/L with normal creatinine: Stop or reduce diuretics cautiously. 1
• Serum sodium 121-125 mmol/L with elevated creatinine (>150 mmol/L): Stop diuretics immediately and give volume expansion with normal saline or colloid. 1
• **Serum sodium <120 mmol/L**: Stop diuretics, provide volume expansion, but avoid increasing sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis. 1, 2
• Reserve fluid restriction (1-1.5 L/day) only for severe hyponatremia (<125 mmol/L) with clinical hypervolemia. 1
• Reserve hypertonic saline (3%) only for severely symptomatic acute hyponatremia. 1

Hyperkalemia:

• Temporarily withhold furosemide while continuing spironolactone at reduced dose. 1
• If severe, substitute amiloride 10-40 mg/day for spironolactone (though less effective). 1, 3

Gynecomastia:

• Substitute amiloride for spironolactone if tender gynecomastia develops. 1

Refractory Ascites

Refractory ascites is defined as fluid overload unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg) with sodium restriction, or rapid recurrence after paracentesis. 2

Treatment options:

• Serial large volume paracentesis every 2 weeks with albumin replacement (8 g/L removed) is first-line treatment. 2, 4
• Consider midodrine on a case-by-case basis. 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for patients requiring frequent paracentesis with relatively preserved liver function. 1, 4

Spontaneous Bacterial Peritonitis Prophylaxis

Primary Prophylaxis:

• Offer to high-risk patients with ascitic protein <1.5 g/dL, using antibiotics guided by local resistance patterns. 1

Secondary Prophylaxis:

• Patients recovering from SBP should receive norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole (800/160 mg daily). 1

GI Bleeding Prophylaxis:

• Patients with GI bleeding and ascites should receive prophylactic antibiotics (cefotaxime or based on local data) to prevent SBP. 1

Critical Precautions

• Absolutely avoid NSAIDs, as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory ascites. 2, 5

• Alcohol abstinence is crucial for ascites control in alcoholic cirrhosis. 1

• Initiate diuretic therapy in hospitalized setting for cirrhotic patients to allow careful titration and monitoring. 6

• Avoid rapid correction of chronic hyponatremia to prevent osmotic demyelination syndrome. 1, 2

Liver Transplantation

Development of ascites is an indication for liver transplantation evaluation, as it represents decompensated cirrhosis with significantly reduced survival (50% at 2-5 years). 1, 2, 4