Management of Ascites Caused by Cirrhosis

Author: Atif Zaman, MD, MPH

Last Updated: September 10, 2010

A 57-year-old woman with chronic hepatitis C infection has cirrhosis that has been complicated by ascites and encephalopathy. She has had a history of hospitalizations for encephalopathy, but currently, her encephalopathy is well controlled on lactulose. Her laboratory studies 4 weeks prior showed a serum total bilirubin of 4.7 mg/dL, albumin 2.3 g/dL, international normalized ratio (INR) 2.0, and creatinine 1.0 mg/dL. Her ascites has been well controlled on furosemide 120 mg daily and spironolactone 300 mg daily, but recently the ascites has become more difficult to control and her furosemide is increased to 160 mg daily and spironolactone to 400 mg daily. Follow-up laboratory studies a week later notably shows that serum sodium has dropped from 132 to 120 mEq/L, serum potassium from 3.6 to 3.0 mEq/L, and creatinine has increased from 1.0 to 1.4 mg/dL. The patient's ascites has not improved. She is classified as Child-Pugh-Turcotte Class C and she has a calculated Model for End-Stage Liver Disease (MELD) score of 23.

What would you recommend as the next step in managing this patient’s ascites?

A Slowly increase diuretics further with close laboratory monitoring.
B Restrict the patient’s fluid intake to 1 liter a day to correct hyponatremia and continue current diuretic doses for another week to see if ascites improves.
C Stop diuretics, perform large volume paracentesis as needed to control ascites, and refer for evaluation of possible liver transplantation.
D Proceed with a transjugular intrahepatic portosystemic shunt (TIPS) procedure to manage the refractory ascites.