A patient with known cirrhosis presents with increasing abdominal distension and rising peripheral edema. What is initial management of ascites?

• A. Immediate large-volume paracentesis without diuretics
• B. Sodium restriction plus diuretic therapy (spironolactone; add furosemide as needed)
• C. High-sodium diet to increase volume
• D. Empiric antibiotics

Answer: (B)

In ascites from cirrhosis, the initial approach is to counteract the sodium and water retention driving the fluid buildup. Restricting dietary sodium and promoting diuresis target the underlying hemodynamic problem caused by portal hypertension and secondary hyperaldosteronism. Spironolactone is favored first because it blocks aldosterone’s effects in the collecting ducts, promoting sodium excretion while conserving potassium. If diuresis is not enough, adding furosemide helps achieve more effective fluid loss and helps balance electrolytes. Together, these measures address the cause of fluid accumulation rather than just removing fluid. A large-volume paracentesis without diuretics is reserved for urgent cases of tense ascites or when diuretics are contraindicated or ineffective, not as the initial step. Antibiotics are reserved for suspected infection such as spontaneous bacterial peritonitis, not routine initial management of ascites. If diuretics fail, other options like repeat paracentesis with albumin, TIPS, or transplant evaluation may be considered.