In a 55-year-old man with liver cirrhosis presenting with hepatic encephalopathy and tense ascites, what is the most appropriate initial management?

Management of Tense Ascites with Hepatic Encephalopathy in Cirrhosis

The most appropriate initial management is therapeutic paracentesis (Option D), which rapidly relieves tense ascites within minutes while avoiding the complications of diuretics in a patient already presenting with hepatic encephalopathy. 1

Rationale for Therapeutic Paracentesis as First-Line

Tense ascites requires immediate large-volume paracentesis because it provides rapid symptom relief and is the guideline-recommended first-line treatment for this presentation. 1, 2 The key advantages in this clinical scenario include:

• Speed of fluid removal: Paracentesis removes fluid in minutes versus days-to-weeks with diuretics, providing immediate relief of respiratory compromise and abdominal discomfort. 1
• Safety in encephalopathy: This patient already has altered mental status, making diuretics particularly hazardous as they commonly cause or worsen hepatic encephalopathy through electrolyte disturbances. 3
• Superior efficacy: Randomized trials demonstrate 96.5% effectiveness for paracentesis versus only 72.8% for diuretics in tense ascites. 3
• Lower complication rates: Paracentesis causes significantly fewer complications than diuretic therapy (17% vs 61% in controlled trials), particularly avoiding encephalopathy worsening, renal impairment, and electrolyte disturbances. 3

Critical Technical Details for Paracentesis

Perform large-volume paracentesis with albumin replacement to prevent post-paracentesis circulatory dysfunction:

• Remove ascitic fluid in a single session until tense ascites is relieved (typically 5-10 liters). 1
• Administer 8 grams of intravenous albumin per liter of ascites removed (approximately 100 ml of 20% albumin per 3 liters removed). 1, 4
• For volumes <5 liters, synthetic plasma expanders (150-200 ml gelofusine or haemaccel) may be used instead of albumin. 1
• Albumin is essential for larger volumes because paracentesis without albumin causes marked activation of the renin-angiotensin-aldosterone system, renal impairment in 20% of patients, and dilutional hyponatremia. 5, 4

Why Other Options Are Inappropriate

Loop diuretics alone (Option A) are contraindicated in this acute presentation:

• They take days-to-weeks to mobilize tense ascites. 1
• They will worsen the existing hepatic encephalopathy through electrolyte disturbances and azotemia. 3
• Furosemide without spironolactone fails to address the aldosterone-driven sodium retention in cirrhosis. 1, 2

Starting diuretics with spironolactone (Option B) is the wrong sequence:

• While this combination is appropriate maintenance therapy, it should only be initiated after paracentesis has relieved the tense ascites. 1, 2
• The guideline-recommended approach is: paracentesis first, then sodium restriction and diuretics to prevent reaccumulation. 1, 2

TIPS (Option C) is reserved for refractory ascites:

• TIPS is indicated only after failure of maximum medical therapy (400 mg/day spironolactone plus 160 mg/day furosemide) or for patients requiring frequent therapeutic paracenteses. 1
• This is a first presentation requiring acute management, not a refractory case. 1

Post-Paracentesis Management Algorithm

After therapeutic paracentesis, implement the following sequence:

1. Sodium restriction to 88 mmol/day (2 g/day, approximately 5 g salt/day) - this is a "no added salt" diet. 1, 2

2. Initiate spironolactone 100 mg daily as the primary diuretic since it directly antagonizes aldosterone. 1, 2

3. Add furosemide 40 mg daily if needed, maintaining a 100:40 mg ratio of spironolactone to furosemide. 1, 2

4. Titrate doses upward every 3-5 days until achieving weight loss of 0.5 kg/day (ascites alone) or 1 kg/day (ascites plus edema), up to maximum doses of 400 mg spironolactone and 160 mg furosemide. 1, 2

5. Monitor electrolytes, creatinine, and weight every 3-5 days initially during diuretic titration. 2

Critical Medications to Avoid

Absolutely avoid NSAIDs as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive ascites to refractory ascites. 1, 6, 2

Liver Transplantation Evaluation

Refer this patient for liver transplantation evaluation immediately because the development of ascites indicates poor prognosis, with 50% mortality at 6 months for refractory ascites and only 56% 5-year survival without transplantation. 1, 2, 7