What is the recommended evaluation and initial management of ascites in a patient with established liver cirrhosis?

Management of Ascites in Liver Cirrhosis

All patients with new-onset or worsening ascites require immediate diagnostic paracentesis to confirm the diagnosis, determine etiology, and exclude spontaneous bacterial peritonitis before initiating any treatment. 1

Initial Diagnostic Evaluation

Mandatory Paracentesis

• Perform diagnostic paracentesis in all patients with new-onset grade 2 or 3 ascites and on every hospital admission for patients with known ascites. 1
• Obtain 10-20 mL of ascitic fluid using a needle inserted approximately 15 cm lateral to the umbilicus in the left or right lower quadrant, avoiding the inferior and superior epigastric arteries. 1
• Paracentesis can be safely performed despite coagulopathy or thrombocytopenia (most clinicians give platelets only if platelet count <40,000). 1

Essential Ascitic Fluid Tests

• Calculate the serum-ascites albumin gradient (SAAG): if ≥1.1 g/dL (or 11 g/L), ascites is due to portal hypertension with 97% accuracy. 1
• Measure total ascitic fluid protein concentration—levels <15 g/L indicate increased risk of spontaneous bacterial peritonitis. 1
• Obtain neutrophil count to rule out SBP (>250 cells/mm³ indicates SBP). 1
• Inoculate 10 mL of ascitic fluid into blood culture bottles at the bedside to maximize bacterial recovery. 1
• Order additional tests (amylase, cytology, adenosine deaminase) only when clinical suspicion exists for pancreatic disease, malignancy, or tuberculosis. 1

Concurrent Laboratory Assessment

• Obtain liver function tests, renal function (creatinine, BUN), serum electrolytes (particularly sodium), prothrombin time, and complete blood count. 1
• Perform abdominal ultrasound to evaluate liver appearance, splenomegaly, portal vein patency, and exclude other causes. 1

Initial Medical Management

Sodium Restriction

• Restrict dietary sodium to 87-113 mmol/day (5-6.5 g salt/day)—this translates to a "no added salt" diet. 1, 2
• Bed rest is not recommended and does not improve outcomes. 1

Diuretic Therapy for Uncomplicated Ascites

• Start with spironolactone monotherapy at 100 mg daily, increasing stepwise to a maximum of 400 mg daily if inadequate response. 1, 2
• If spironolactone alone fails to resolve ascites, add furosemide up to 160 mg daily with careful biochemical monitoring. 1
• For recurrent or severe ascites requiring hospitalization, combination therapy may be initiated with spironolactone 100 mg plus furosemide 40 mg daily. 2
• Target weight loss should be 0.5 kg/day without peripheral edema, or 1 kg/day with peripheral edema. 2
• Monitor serum electrolytes, creatinine, and body weight closely during diuretic therapy. 2

Management of Hyponatremia During Treatment

• Serum sodium 126-135 mmol/L with normal creatinine: Continue diuretics but monitor electrolytes closely; do not restrict water. 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 or >120 mmol/L and rising): Stop diuretics immediately and give volume expansion. 1
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion with colloid or saline, but avoid increasing sodium by >12 mmol/L per 24 hours to prevent osmotic demyelination. 1

Management of Large or Tense Ascites

Therapeutic Paracentesis

• Large volume paracentesis is the first-line treatment for patients with large or tense ascites. 1
• Perform paracentesis in a single session regardless of volume removed. 1
• For paracentesis <5 liters: Give synthetic plasma expander (150-200 mL of gelofusine or haemaccel); albumin is not required. 1
• For large volume paracentesis ≥5 liters: Give 8 g albumin per liter of ascites removed (approximately 100 mL of 20% albumin per 3 liters removed) once paracentesis is complete. 1
• Continue diuretic therapy after paracentesis to prevent reaccumulation. 3

Spontaneous Bacterial Peritonitis Management

When to Suspect SBP

• Perform diagnostic paracentesis immediately in patients with fever, abdominal pain, altered mental status, hepatic encephalopathy, worsening renal function, GI bleeding, shock, or any signs of systemic inflammation. 1

Treatment of SBP

• Start empirical antibiotic therapy immediately when ascitic neutrophil count >250 cells/mm³, without waiting for culture results. 1
• Third-generation cephalosporins (cefotaxime) are the most extensively studied and effective treatment, though antibiotic choice should be guided by local resistance patterns and whether infection is community-acquired or healthcare-associated. 1
• Give albumin 1.5 g/kg within the first 6 hours, followed by 1 g/kg on day 3 in patients with SBP who have signs of developing renal impairment to prevent hepatorenal syndrome and reduce mortality. 1
• Consider repeat paracentesis at 48 hours if inadequate clinical response or if secondary bacterial peritonitis is suspected. 1

SBP Prophylaxis

• Patients recovering from one episode of SBP require lifelong secondary prophylaxis with norfloxacin 400 mg daily (or ciprofloxacin 500 mg once daily). 1
• Patients with GI bleeding and ascites should receive prophylactic antibiotics (cefotaxime or similar based on local protocols). 1
• Primary prophylaxis may be considered in patients with ascitic fluid protein <15 g/L plus additional risk factors (Child-Pugh score ≥9, serum bilirubin ≥3 mg/dL, renal impairment, or hyponatremia). 2

Refractory Ascites

Definition and Management Options

• Refractory ascites is defined as ascites unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily) with sodium restriction, or ascites that recurs rapidly after therapeutic paracentesis. 1
• Treatment options include repeated large volume paracentesis with albumin or transjugular intrahepatic portosystemic shunt (TIPS). 1
• TIPS is more effective for long-term control of refractory ascites but may impair hepatic function and induce chronic hepatic encephalopathy; careful risk-benefit assessment is required. 1, 3

Critical Prognostic Considerations

Liver Transplantation Referral

• The development of ascites marks hepatic decompensation and should trigger immediate referral for liver transplantation evaluation, as 5-year survival drops below 50%. 1, 2, 4
• All patients with SBP should be considered for liver transplantation referral, as this complication further worsens prognosis. 1
• Treatment of ascites improves quality of life and prevents complications but does not significantly improve survival without transplantation. 1

Common Pitfalls to Avoid

• Never assume the cause of ascites without performing diagnostic paracentesis—approximately 25% of cases in Western populations are due to non-cirrhotic causes (malignancy, heart failure, tuberculosis, pancreatic disease). 1
• Do not routinely use albumin for uncomplicated ascites management; reserve it for large volume paracentesis (≥5L), SBP treatment, or hepatorenal syndrome. 2
• Avoid aggressive diuresis leading to hyponatremia, renal dysfunction, or hepatic encephalopathy—these complications worsen outcomes. 1
• Do not delay paracentesis due to coagulopathy concerns; serious bleeding complications occur in <1/1000 procedures. 1