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

Therapeutic Paracentesis is the Most Appropriate Immediate Management

In a 55-year-old man with decompensated cirrhosis presenting with tense ascites, decreased consciousness (hepatic encephalopathy), and bilateral edema, therapeutic large-volume paracentesis is the first-line treatment because it provides immediate symptom relief within minutes, whereas diuretics require days to weeks to achieve comparable effects. 1

Why Therapeutic Paracentesis First

• Tense ascites requires urgent decompression because large-volume paracentesis relieves abdominal discomfort and respiratory compromise immediately, while diuretic therapy takes 5 days to several weeks to mobilize comparable fluid volumes. 2, 1

• Two randomized controlled trials (158 patients) demonstrated that large-volume paracentesis was safer and more effective than high-dose diuretics for tense ascites, with significantly lower rates of hepatic encephalopathy, renal impairment, electrolyte abnormalities, and hemodynamic disturbances in the paracentesis group. 2

• In patients with altered mental status (hepatic encephalopathy), aggressive diuresis increases the risk of worsening encephalopathy, hepatorenal syndrome, and intravascular volume depletion (occurring in approximately 25-28% of cases). 1

Albumin Administration During Paracentesis

• Administer intravenous albumin at 8 g per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction and maintain hemodynamic stability. 2, 1

• For removal of >5 L, albumin supplementation is strongly recommended; for ≤5 L, albumin can be considered in patients with acute-on-chronic liver failure or high risk of acute kidney injury. 2

Diagnostic Evaluation During Paracentesis

• Send ascitic fluid for cell count and culture immediately because spontaneous bacterial peritonitis (SBP) occurs in 10-30% of hospitalized cirrhotic patients and is a frequent trigger of hepatic encephalopathy. 1

• An ascitic neutrophil count >250 cells/mm³ confirms SBP and mandates immediate empiric antibiotic therapy. 1

• Bedside inoculation of ascitic fluid into blood-culture bottles increases pathogen detection yield. 1

Why NOT Loop Diuretics Alone (Option A)

• Loop diuretics (furosemide) alone have limited efficacy in cirrhosis and can precipitate rapid electrolyte disturbances that worsen encephalopathy. 1

• Diuretic monotherapy without prior decompression leaves patients symptomatic for days to weeks. 1

Why NOT Start Diuretics Immediately (Option B)

• While spironolactone plus furosemide is the correct maintenance regimen after paracentesis, starting diuretics without first draining tense ascites fails to address the immediate life-threatening symptoms. 1

• The FDA label for furosemide specifically warns that "in patients with hepatic cirrhosis and ascites, therapy is best initiated in the hospital" and that "sudden alterations of fluid and electrolyte balance may precipitate hepatic coma." 3

• Over-diuresis in patients with altered mental status carries a 26% risk of worsening hepatic encephalopathy. 1

Why NOT TIPS (Option C)

• TIPS is indicated only for refractory ascites—defined as ascites unresponsive to maximal diuretic therapy (spironolactone 400 mg + furosemide 160 mg daily) with sodium restriction, or ascites that recurs rapidly after repeated paracenteses. 2, 1

• TIPS is not appropriate for initial management of tense ascites and requires caution in patients with current hepatic encephalopathy, age >70 years, bilirubin >50 μmol/L, or MELD score ≥18. 2

Post-Paracentesis Management Algorithm

After therapeutic paracentesis, initiate the following within 1-2 days:

• Sodium restriction to 88-90 mmol/day (2000 mg/day) to prevent rapid ascites reaccumulation, which occurs in 93% of patients without diuretics. 1, 4

• Start spironolactone 100 mg daily plus furosemide 40 mg daily (maintaining a 100:40 ratio) to address underlying sodium retention. 1, 4

• Titrate doses upward every 3-5 days if weight loss is inadequate, up to maximum doses of spironolactone 400 mg and furosemide 160 mg daily. 1, 5

• Target weight loss of 0.5 kg/day in patients without peripheral edema, or 1 kg/day with edema present. 2

Critical Pitfalls to Avoid

• Never prescribe NSAIDs because they cause acute renal failure, hyponatremia, and diuretic resistance in cirrhotic patients. 1, 4

• Do not delay diuretic initiation beyond 2 days post-paracentesis because ascites will rapidly reaccumulate. 4

• Monitor for post-paracentesis circulatory dysfunction by checking serum creatinine, sodium, and mental status daily for 2-3 days, as PPCD occurs in 18.5% of patients even with albumin replacement. 4

• Avoid rapid correction of hyponatremia (>12 mmol/L in 24 hours) to prevent osmotic demyelination syndrome. 1

• Routine correction of coagulopathy (INR or platelets) before paracentesis is not recommended unless active bleeding occurs. 2, 6

Prognostic Considerations

• Development of ascites in cirrhosis confers a 50% mortality risk within 2 years; once ascites becomes refractory, mortality rises to 50% within 6 months. 1

• This patient should be evaluated promptly for liver transplantation eligibility given the poor short-term prognosis with decompensated cirrhosis. 1, 4