Management of Ascites in Cirrhotic Patients

Diagnostic Approach

The European Association for the Study of the Liver recommends performing a diagnostic paracentesis in all cirrhotic patients with ascites on hospital admission to rule out spontaneous bacterial peritonitis and assess ascitic fluid characteristics 3
Initial ascitic fluid analysis should include serum ascites-albumin gradient (SAAG) rather than ascitic protein, as recommended by the European Association for the Study of the Liver 3
The American Association for the Study of Liver Diseases suggests inoculating ascitic fluid into blood culture bottles at bedside and examining for neutrophil count 1

The American Association for the Study of Liver Diseases recommends restricting dietary sodium to 90 mmol/day (5.2 g salt/day) - "no added salt" diet, for patients with cirrhosis and ascites 1, 2
Bed rest is not recommended for treatment of ascites, according to the American Association for the Study of Liver Diseases 1, 3
The European Association for the Study of the Liver suggests beginning with spironolactone 100 mg/day as monotherapy for moderate ascites, with a gradual increase in dose every 7 days up to 400 mg/day if needed 1, 4, 5

For patients with recurrent ascites, the American Association for the Study of Liver Diseases recommends considering combination therapy with spironolactone and furosemide from the beginning 2, 4
If there is an inadequate response to spironolactone alone, the European Association for the Study of the Liver suggests adding furosemide 40 mg/day, increasing up to 160 mg/day with careful monitoring 1, 5
The American Association for the Study of Liver Diseases recommends maintaining a spironolactone:furosemide ratio of 100 mg:40 mg to maintain normokalemia 5

The European Association for the Study of the Liver recommends targeting a weight loss of 0.5 kg/day in patients without peripheral edema and 1 kg/day in those with edema 4
The American Association for the Study of Liver Diseases suggests monitoring serum electrolytes, especially sodium and potassium 1
The European Association for the Study of the Liver recommends assessing spot urine sodium:potassium ratio to evaluate diuretic response (target ratio between 1.8-2.5) 2

For serum sodium 126-135 mmol/L with normal creatinine, the American Association for the Study of Liver Diseases recommends continuing diuretic therapy with close monitoring 1, 3
For serum sodium 121-125 mmol/L with normal creatinine, the European Association for the Study of the Liver suggests considering pausing diuretics or adopting a more cautious approach 1, 3
For serum sodium 121-125 mmol/L with elevated creatinine, the American Association for the Study of Liver Diseases recommends stopping diuretics and giving volume expansion 1, 3
For serum sodium <120 mmol/L, the European Association for the Study of the Liver suggests stopping diuretics and considering volume expansion with colloid or saline 1, 3

The European Association for the Study of the Liver recommends therapeutic paracentesis as first-line treatment for patients with large or refractory ascites 3
For paracentesis <5 liters, the American Association for the Study of Liver Diseases suggests using synthetic plasma expander (150-200 ml of gelofusine or haemaccel) 3
For large volume paracentesis, the European Association for the Study of the Liver recommends administering albumin at 8 g/L of ascites removed 3

The American Association for the Study of Liver Diseases recommends considering liver transplantation in eligible patients with cirrhotic ascites and HCC 3, 6

The European Association for the Study of the Liver warns against overzealous diuresis which can lead to renal failure, hepatic encephalopathy, and electrolyte disorders 4
The American Association for the Study of Liver Diseases notes that spironolactone may cause gynecomastia; amiloride (10-40 mg/day) can be substituted but is less effective 5
The European Association for the Study of the Liver recommends avoiding furosemide monotherapy as it is less effective than spironolactone and should not be used alone 5