How should I manage a patient with cirrhosis who presents with ascites?

Management of a patient with cirrhosis presenting with ascites involves a comprehensive approach including assessment, symptomatic treatment, prevention of complications, and specialist referral. Initially, confirm the diagnosis of ascites and assess for signs of decompensated liver disease, which may necessitate urgent hospital admission or referral to hepatology NICE CKS.

Symptomatic management includes sodium restriction and diuretic therapy, typically starting with spironolactone and adding furosemide if needed, to mobilize ascitic fluid. Monitor renal function and electrolytes closely during diuretic treatment NICE CKS.

For refractory ascites not responding to diuretics, consider large volume paracentesis, which can be safely performed in nurse-led day case settings to reduce hospital admissions and improve patient experience NICE CKS. Albumin infusion should accompany large volume paracentesis to prevent circulatory dysfunction NICE CKS.

Consider transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites as a specialist intervention to reduce portal hypertension and ascitic fluid accumulation NICE NG50.

Prevent spontaneous bacterial peritonitis (SBP) by assessing risk; routine antibiotic prophylaxis is not recommended but may be considered in high-risk patients (e.g., low ascitic protein, high Child-Pugh or MELD scores) or when infection consequences could severely impact outcomes NICE CKS.

Monitor for complications such as hepatic encephalopathy, which may require lactulose and/or rifaximin therapy NICE CKS.

Ensure the patient is under specialist follow-up for surveillance of hepatocellular carcinoma and oesophageal varices, and provide lifestyle advice including alcohol reduction, weight management, and nutritional support to prevent further liver damage NICE CKS.

Review medications carefully for liver function impact and advise against over-the-counter or herbal remedies without medical advice NICE CKS.

In cases of complicated umbilical hernia associated with ascites, surgical management may be necessary, with careful perioperative planning due to the risks posed by ascites and liver dysfunction Elsebae et al. 2006.

This integrated approach aligns with NICE and BSG guidelines and is supported by clinical literature emphasizing the importance of multidisciplinary care and tailored interventions to improve outcomes in cirrhotic patients with ascites NICE CKS; Ginès et al. 1989.