Management of Ascites in Cirrhosis

Initial Diagnostic Evaluation

The European Association for the Study of the Liver recommends that all patients with new-onset ascites require diagnostic paracentesis immediately to establish the etiology and exclude infection, which carries high mortality risk 1, 2
Essential ascitic fluid tests include cell count with differential, ascitic fluid albumin or total protein, and calculation of serum-ascites albumin gradient (SAAG) to detect spontaneous bacterial peritonitis and confirm portal hypertension as the cause 1, 2, 4
The American Association for the Study of Liver Diseases suggests that a SAAG ≥1.1 g/dL indicates portal hypertension, while SAAG <1.1 g/dL suggests non-portal hypertension causes 4
Inoculate ascitic fluid into blood culture bottles at the bedside before starting antibiotics if infection is suspected, as recommended by the European Association for the Study of the Liver 1, 2
Repeat diagnostic paracentesis at every hospital admission to rule out spontaneous bacterial peritonitis, which carries high mortality and requires prompt treatment 1, 2

The American College of Gastroenterology recommends restricting sodium intake to 88 mmol/day (2000 mg/day) combined with oral diuretics, starting with spironolactone 100 mg daily, and adding furosemide 40 mg daily as needed 1, 2, 3
More stringent sodium restriction can accelerate fluid mobilization but risks worsening malnutrition, which is already common in cirrhotic patients, according to the American Association for the Study of Liver Diseases 4, 3
Fluid restriction is not necessary unless serum sodium falls below 120-125 mmol/L, as recommended by the European Association for the Study of the Liver 5, 3
Weight loss correlates directly with sodium balance, and it is sodium restriction, not fluid restriction, that drives diuresis, according to the American Association for the Study of Liver Diseases 4

Start with spironolactone 100 mg once daily as the initial diuretic, as secondary hyperaldosteronism is the primary driver of sodium retention in cirrhosis, recommended by the American College of Gastroenterology 4, 5, 3
Add furosemide 40 mg once daily if spironolactone alone is insufficient or if hyperkalemia develops, as suggested by the European Association for the Study of the Liver 4, 5, 3
Maximum doses are 400 mg/day spironolactone and 160 mg/day furosemide, maintaining a ratio of approximately 100:40, according to the American Association for the Study of Liver Diseases 1, 5, 3
Monotherapy with loop diuretics alone is not recommended, as aldosterone antagonists are the mainstay, recommended by the European Association for the Study of the Liver 5

Perform large-volume paracentesis (>5 L) as first-line treatment for tense ascites to provide rapid symptom relief, recommended by the American College of Gastroenterology 1, 2, 3
Administer intravenous albumin at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction, which increases mortality, suggested by the European Association for the Study of the Liver 1, 3
For paracentesis <5 L, synthetic plasma expanders (150-200 mL gelofusine or haemaccel) may be used instead of albumin, according to the American Association for the Study of Liver Diseases 6

Refractory ascites is defined as fluid overload unresponsive to maximum-dose diuretics or rapid recurrence after therapeutic paracentesis, according to the American College of Gastroenterology 1, 3
Serial large-volume paracentesis every 2-3 weeks with albumin infusion remains the most common palliative approach, recommended by the European Association for the Study of the Liver 1, 2
Transjugular intrahepatic portosystemic shunt (TIPS) is effective in reducing need for repeated drainage but requires careful patient selection, suggested by the American Association for the Study of Liver Diseases 1, 2, 3
Liver transplantation is the only curative option and should be considered for all patients with refractory ascites, regardless of MELD score, recommended by the American College of Gastroenterology 1, 6

Nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory status, according to the American Association for the Study of Liver Diseases 3, 7
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers should be discontinued as they worsen hypotension in cirrhotic patients, recommended by the European Association for the Study of the Liver 5, 3, 7

Alcohol cessation is the single most effective intervention for alcoholic cirrhosis with ascites, with approximately 75% 3-year survival in abstinent patients versus 0% in those who continue drinking, according to the American Association for the Study of Liver Diseases 3
Abstinence can result in dramatic improvement even in advanced disease, making ascites more responsive to medical therapy, suggested by the European Association for the Study of the Liver 4, 3

If ascitic fluid neutrophil count >250 cells/mm³, start empiric antibiotics immediately before culture results, recommended by the American College of Gastroenterology 1, 2, 6
Third-generation cephalosporins (cefotaxime) are first-line therapy for spontaneous bacterial peritonitis, according to the European Association for the Study of the Liver 6
Administer albumin 1.5 g/kg within 6 hours, then 1 g/kg on day 3 to patients with spontaneous bacterial peritonitis and signs of renal impairment to prevent hepatorenal syndrome, suggested by the American Association for the Study of Liver Diseases 6
After recovery from one episode, provide continuous prophylaxis with norfloxacin 400 mg/day (or ciprofloxacin 500 mg once daily) to prevent recurrence, recommended by the American College of Gastroenterology 1, 6

Development of ascites marks a critical milestone with approximately 20% mortality in the first year of diagnosis, according