In a 55-year-old man with decompensated cirrhosis presenting with hepatic encephalopathy, tense ascites, and bilateral lower-extremity pitting edema, what is the most appropriate immediate management?

Management of Decompensated Cirrhosis with Tense Ascites and Hepatic Encephalopathy

The most appropriate immediate management is therapeutic paracentesis (Option D), followed by initiation of diuretics and treatment of hepatic encephalopathy. 1, 2

Rationale for Therapeutic Paracentesis as First-Line

Large-volume paracentesis is the treatment of choice for tense ascites because it rapidly relieves symptoms within minutes, compared to diuretics which take days to weeks. 3, 1 This patient presents with:

• Tense ascites requiring immediate decompression 1, 2
• Decreased level of consciousness (hepatic encephalopathy) that may worsen with diuretic-induced electrolyte disturbances 3
• Cachexia and decompensation indicating advanced disease 3

Why Not Diuretics Alone?

Starting with diuretics alone (Options A or B) is inappropriate in this acute presentation for several critical reasons:

• Loop diuretics alone have low efficacy in cirrhosis and can cause rapid electrolyte disturbances, worsening encephalopathy 3
• Diuretics take days to weeks to mobilize fluid, leaving the patient symptomatic with tense ascites 3
• Over-diuresis causes intravascular volume depletion (25%), hepatic encephalopathy (26%), and hyponatremia (28%) 3
• In the setting of altered mental status, aggressive diuresis risks precipitating hepatorenal syndrome and worsening encephalopathy 3

Why Not TIPS?

TIPS (Option C) is reserved for refractory ascites, defined as fluid unresponsive to maximum diuretic doses (400 mg spironolactone + 160 mg furosemide) with sodium restriction, or rapid recurrence after paracentesis. 3, 4, 2 This patient has not yet failed medical therapy, making TIPS premature and unnecessarily risky.

Correct Management Algorithm

Step 1: Immediate Therapeutic Paracentesis

• Perform large-volume paracentesis to remove tense ascites 1, 2
• Administer albumin at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 3, 1, 2
• A single 5-L paracentesis can be performed safely without colloid if smaller volume, but albumin is preferred for larger volumes 3

Step 2: Diagnostic Paracentesis

Simultaneously obtain ascitic fluid for analysis to rule out spontaneous bacterial peritonitis (SBP), which occurs in 10-30% of hospitalized cirrhotic patients with ascites and can precipitate encephalopathy. 3

• Ascitic neutrophil count >250 cells/mm³ confirms SBP and requires immediate antibiotic therapy 3
• Inoculate ascitic fluid into blood culture bottles at bedside 3

Step 3: Treat Hepatic Encephalopathy

• Start lactulose to achieve 2-3 soft stools daily 5
• Initial dosing: 30-45 mL (20-30 g) three to four times daily, adjusted to clinical response 5
• Improvement may occur within 24-48 hours 5

Step 4: Initiate Maintenance Diuretic Therapy

After paracentesis, start combination diuretic therapy to prevent reaccumulation:

• Spironolactone 100 mg daily plus furosemide 40 mg daily in a 100:40 ratio to maintain normokalemia 1, 4, 2
• Titrate every 3-5 days up to maximum doses (spironolactone 400 mg, furosemide 160 mg) based on response 1, 4
• Sodium restriction to 88 mmol/day (2000 mg/day or 5-6 g salt/day) 1, 4, 2

Step 5: Monitor for Complications

• Target weight loss: 0.5 kg/day without edema, 1 kg/day with edema 4, 2
• Monitor electrolytes, renal function, and mental status closely 1, 4
• Fluid restriction is NOT necessary unless serum sodium <120-125 mmol/L 3, 4

Critical Pitfalls to Avoid

• Never use NSAIDs in cirrhotic patients with ascites—they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory 3, 4
• Do not perform serial paracenteses without diuretics in diuretic-sensitive patients, as this fails to address underlying sodium retention 3, 1
• Avoid rapid correction of hyponatremia (>12 mmol/L per 24 hours) to prevent central pontine myelinolysis 3, 4
• Do not start with loop diuretics alone—spironolactone has greater natriuretic potency in cirrhosis 3, 6

Long-Term Considerations

The development of ascites carries 50% mortality within 2 years, and this patient should be evaluated for liver transplantation. 3, 2 Once ascites becomes refractory to medical therapy, 50% die within 6 months. 3