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Ascites — ABIM Board MCQ

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ModerateGastroenterology/HepatologyAscitesABIM Board

A 58-year-old man with alcohol-associated cirrhosis has marked abdominal distention and early satiety from tense ascites. He is afebrile and has no abdominal tenderness or encephalopathy. Diagnostic paracentesis shows a serum-ascites albumin gradient of 1.8 g/dL and an ascitic fluid neutrophil count of 80 cells/mm3. Serum creatinine is 0.9 mg/dL, and sodium is 136 mEq/L. Which of the following is the most appropriate immediate management?

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Correct answer: A — Perform large-volume paracentesis and give intravenous albumin if more than 5 L is removed

The correct answer is A. Tense ascites causing early satiety warrants therapeutic large-volume paracentesis for prompt symptom relief. If more than 5 L is removed, intravenous albumin, generally 6–8 g per liter removed, reduces the risk of post-paracentesis circulatory dysfunction and renal impairment. The elevated SAAG confirms portal hypertensive ascites. An ascitic neutrophil count of 80 cells/mm3 is below the 250 cells/mm3 threshold for spontaneous bacterial peritonitis, so empiric ceftriaxone is not indicated. TIPS is generally considered for recurrent or refractory ascites rather than as the initial procedure for an uncomplicated episode. Nonselective beta-blocker escalation does not treat tense ascites and may worsen circulatory dysfunction in susceptible patients. Fluid restriction is reserved primarily for clinically significant hypervolemic hyponatremia; this patient's sodium is normal.

Reference: Biggins SW, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048. https://pubmed.ncbi.nlm.nih.gov/33942342/