Management of Ascites in Cirrhosis

Initial Assessment and Classification

The European Association for the Study of the Liver (EASL) recommends diagnostic paracentesis for all patients with new-onset grade 2-3 ascites or hospitalized patients with worsening ascites 3
Ascitic fluid should be analyzed for neutrophil count, culture, total protein, and SAAG (serum-ascites albumin gradient) to determine etiology 3
Ascites is classified as grade 1 (mild, only detectable by ultrasound), grade 2 (moderate, with symmetrical abdominal distension), or grade 3 (large or tense with marked distension) 2, 3

The EASL recommends a moderately salt-restricted diet with daily intake of 5-6.5g salt (87-113 mmol sodium) for patients with ascites 1, 4
A "no added salt" diet with avoidance of precooked meals is recommended for patients with ascites 1, 5
The EASL suggests spironolactone monotherapy (starting dose 100mg, increased to maximum 400mg) for first presentation of moderate ascites 1, 6
For recurrent or severe ascites, the EASL recommends combination therapy with spironolactone (starting at 100mg, up to 400mg) and furosemide (starting at 40mg, up to 160mg) 1, 6
Diuretic doses should be increased every 7 days until adequate response is achieved 2
Target weight loss should be 0.5 kg/day in patients without edema and 1 kg/day in those with edema 6, 7

Hypovolaemic hyponatremia (due to excessive diuresis): Discontinue diuretics and expand plasma volume with normal saline 1, 6
Hypervolaemic hyponatremia: Fluid restriction (1-1.5 L/day) should be reserved only for patients with severe hyponatremia (serum sodium <125 mmol/L) 1, 6, 4
Hypertonic sodium chloride (3%) should be used only for severely symptomatic patients with acute hyponatremia 1
Refractory ascites is defined as ascites that cannot be mobilized despite maximum diuretic therapy (spironolactone 400mg/day and furosemide 160mg/day) for at least 1 week, salt restriction <5g/day, and mean weight loss <800g over 4 days and urinary sodium output less than intake 7
The EASL recommends large volume paracentesis (LVP) with albumin replacement for refractory ascites 1, 7
Transjugular intrahepatic portosystemic shunt (TIPSS) should be considered in patients with refractory ascites 1, 7
Midodrine may be considered on a case-by-case basis for refractory ascites 1, 7

In patients with spontaneous bacterial peritonitis (SBP) and increased or rising serum creatinine, albumin infusion (1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3) is recommended 1
The EASL suggests that development of ascites indicates poor prognosis and should prompt consideration for liver transplantation 5, 3
Liver transplantation is the ultimate treatment for ascites and its complications 5