Cirrhosis & Ascites
End-stage liver disease with portal hypertension. Ascites is the most common complication -present in ~60% within 10 years. Every new ascites or admission needs a diagnostic paracentesis. Always tap -it changes management more than you expect.
🔍 Overview
Child-Pugh Classification
| Parameter | 1 Point | 2 Points | 3 Points |
|---|---|---|---|
| Bilirubin | < 2 | 2–3 | > 3 |
| Albumin | > 3.5 | 2.8–3.5 | < 2.8 |
| INR | < 1.7 | 1.7–2.3 | > 2.3 |
| Ascites | None | Mild (controlled) | Moderate-severe (refractory) |
| Encephalopathy | None | Grade I–II | Grade III–IV |
A (5–6): 1-yr survival ~100%. B (7–9): ~80%. C (10–15): ~45%. Child-Pugh C = decompensated → transplant evaluation.
MELD-Na Score
- MELD-Na = 3.78 × ln(bilirubin) + 11.2 × ln(INR) + 9.57 × ln(creatinine) + 1.32 × (137 − Na) − 0.025 × MELD + 6.43
- Used for transplant listing priority. Higher MELD = sicker = higher priority on the waitlist.
- MELD ≥ 15: transplant generally beneficial over medical management
- MELD ≥ 30: 3-month mortality > 50% without transplant
Decompensation Events
Development of any of these marks the transition from compensated to decompensated cirrhosis -median survival drops from > 12 years to ~2 years. Triggers transplant evaluation.
- Ascites -most common (see Ascites Management tab)
- Variceal hemorrhage -see Upper GI Bleed
- Hepatic encephalopathy -see Hepatic Encephalopathy
- SBP -see Spontaneous Bacterial Peritonitis
- Hepatorenal syndrome (HRS) -functional renal failure from splanchnic vasodilation
- Jaundice (bilirubin > 3 with liver failure)
💧 Ascites Management
Diagnostic Paracentesis -Always Tap
Every new-onset ascites, every admission, and every clinical deterioration in a cirrhotics requires diagnostic paracentesis. SBP is present in ~15% of cirrhotics admitted to hospital -often asymptomatic. You will miss it without tapping.
| Send | Why |
|---|---|
| Cell count + differential | PMN ≥ 250/mm³ = SBP (treat immediately -don't wait for culture). This is the most important test. |
| Albumin | Calculate SAAG (serum albumin − ascites albumin). SAAG ≥ 1.1 = portal hypertension (cirrhosis, HF, Budd-Chiari). SAAG < 1.1 = non-portal (malignancy, TB, nephrotic, pancreatitis). |
| Total protein | Ascites protein < 1.5 g/dL = high risk for SBP → consider prophylaxis. |
| Culture (blood culture bottles at bedside) | Inoculate aerobic + anaerobic blood culture bottles with 10 mL each. Bedside inoculation ↑ yield from ~50% to ~80%. |
| Glucose, LDH, gram stain | If concerned for secondary peritonitis (perforation): glucose < 50, LDH > serum, polymicrobial → CT + surgery. |
INR is NOT a contraindication to paracentesis. Cirrhotics are auto-anticoagulated but also auto-procoagulant (rebalanced hemostasis). Bleeding complications are < 1% even with INR > 2 and platelets < 50K. Do NOT transfuse FFP or platelets before a paracentesis.
Ascites Treatment
Step 1 -Sodium restriction
2g Na/day (< 88 mEq/day). This alone controls ascites in ~10–15%. Fluid restriction only if Na < 125 (dilutional hyponatremia).
Step 2 -Diuretics
Spironolactone 100 mg + furosemide 40 mg daily (100:40 ratio maintains K⁺ balance) AASLD Guidelines, 2021. Titrate every 3–5 days. Max: spironolactone 400 mg + furosemide 160 mg. Monitor weight (target loss 0.5 kg/day without edema, 1 kg/day with edema), BMP, Cr.
Step 3 -Large volume paracentesis (LVP)
If tense ascites or diuretic-refractory. Remove 5–8+ liters per session. If removing > 5 L → give albumin 6–8 g per liter removed (prevents post-paracentesis circulatory dysfunction) Ginès, 1988.
Step 4 -Refractory ascites
TIPS (transjugular intrahepatic portosystemic shunt) -reduces portal pressure, resolves ascites in ~75% Salerno, 2007. Risk: hepatic encephalopathy (30–50%). Contraindicated if: Child-Pugh > 13, MELD > 18 (relative), active HE, right heart failure. Or serial LVP q2 weeks + albumin.
⚠️ Key Complications
Hepatorenal Syndrome (HRS)
- Functional renal failure -kidneys are structurally normal but underperfused due to splanchnic vasodilation + renal vasoconstriction
- HRS-AKI (Type 1): rapid Cr rise > 2× baseline in < 2 weeks. Median survival 2 weeks without treatment.
- HRS-CKD (Type 2): gradual, stable Cr elevation. Associated with refractory ascites.
- Diagnosis: no response to volume challenge (albumin 1 g/kg × 2 days), no shock, no nephrotoxins, no parenchymal disease on UA/imaging
- Treatment: Albumin 20–40 g/day + octreotide 200 mcg SC TID + midodrine 7.5–15 mg TID (splanchnic vasoconstrictors). Or norepinephrine drip in ICU (more effective). Definitive treatment: liver transplant. CONFIRM, 2021: terlipressin FDA-approved for HRS-AKI (improved renal function in ~30%).
Variceal Prophylaxis
| Setting | Management |
|---|---|
| No varices | EGD screening. Repeat in 2–3 years (compensated) or 1 year (decompensated). |
| Small varices, no red signs | NSBB (propranolol 20–40 mg BID or nadolol 20–40 mg daily or carvedilol 6.25–12.5 mg daily Bañares, 2002). Target HR reduction 25% or HR 55–60. |
| Medium/large varices | NSBB (carvedilol preferred) OR endoscopic variceal ligation (EVL). Both are first-line for primary prophylaxis. PREDESCI, 2019: NSBB in compensated cirrhosis with CSPH delayed decompensation. |
| Post-bleed (secondary prophylaxis) | NSBB + EVL (combination is superior to either alone) Lo, 2012. TIPS if rebleeding despite combo Early-TIPS, 2010. |
🧪 Workup
Workup
- CBC, BMP, LFTs, INR, albumin
- MELD-Na
- RUQ US + AFP q6mo -HCC screening
- EGD -variceal screening
- Paracentesis -new ascites or clinical change
- Hepatitis serologies
- Autoimmune/metabolic panel
🚨 Management
Management
- Ascites: Na restrict 2g/day + spiro/furosemide 100:40. LVP+albumin. TIPS if refractory.
- Varices: nadolol prophylaxis. Bleed: octreotide+ceftriaxone+banding.
- HE: lactulose+rifaximin. Find precipitant.
- SBP: ceftriaxone+albumin. Lifelong prophylaxis.
- HCC: US+AFP q6mo.
- Transplant: refer MELD≥15.
📋 On Rounds
Why give albumin after large volume paracentesis?
Removing > 5 L of ascites causes post-paracentesis circulatory dysfunction (PPCD) -the rapid reduction in intra-abdominal pressure causes splanchnic vasodilation → effective hypovolemia → RAAS activation → sodium retention → faster ascites recurrence → HRS. Ginès, 1988 showed that albumin 6–8 g per liter removed prevents PPCD by expanding the intravascular volume. No other volume expander (NS, dextran, gelatin)
Why is INR NOT a contraindication to paracentesis in cirrhosis?
Cirrhotic coagulopathy is a rebalanced hemostasis -both procoagulant factors (II, VII, IX, X) AND anticoagulant factors (protein C, protein S, antithrombin) are reduced proportionally. The INR measures only the procoagulant side and overestimates bleeding risk. Multiple large studies show bleeding complications from paracentesis are < 1% even with INR > 2 and platelets < 50K.
What is the management of refractory ascites, and when do you consider TIPS?
Refractory ascites = doesn't respond to max diuretics (spironolactone 400 + furosemide 160) or diuretic-induced complications prevent dose escalation. Options: (1) Serial large-volume paracentesis (LVP) every 2-4 weeks + albumin infusion (6-8g per liter if > 5L drained). (2) TIPS (transjugular intrahepatic portosystemic shunt): reduces portal pressure → ascites resolves in ~75%.
What HCC screening do you order and how often?
Ultrasound + AFP (alpha-fetoprotein) every 6 months in all cirrhotic patients regardless of etiology. This is one of the most commonly missed screening protocols. If US is limited (obesity, nodular liver) → consider CT or MRI. If a lesion is found: LI-RADS classification on contrast-enhanced CT or MRI. LI-RADS 5 = definite HCC (arterial enhancement + washout on portal/delayed phase).
Clinical Examples
📋 Case 1, Tense Ascites with SBP
Patient: 58 y/o M with alcohol-related cirrhosis (Child-Pugh C, MELD-Na 22), presents with abdominal distension, fever 38.4°C, and diffuse abdominal pain.
Key findings: Tense ascites, shifting dullness. Paracentesis: PMN 680/mm³, SAAG 2.4. WBC 14K.
Management:
- Ceftriaxone 2g IV daily for SBP (PMN ≥ 250 = treat, do not wait for cultures)
- IV albumin 1.5 g/kg on day 1, 1 g/kg on day 3 Sort, 1999
- Therapeutic LVP + albumin 6-8g/L if > 5L removed Gines, 1988
- Lifelong SBP prophylaxis after resolution: norfloxacin or TMP-SMX
Teaching point: Any cirrhotic with fever, abdominal pain, or encephalopathy needs diagnostic paracentesis before antibiotics. PMN ≥ 250 = SBP regardless of culture result.
📋 Case 2, Acute Variceal Hemorrhage
Patient: 62 y/o M with HCV cirrhosis, large-volume hematemesis. Known varices, not on beta-blocker prophylaxis.
Key findings: HR 128, BP 82/48, Hgb 6.2, INR 2.1, platelets 68K.
Management:
- Octreotide 50 mcg IV bolus then 50 mcg/hr (reduces portal pressure)
- Ceftriaxone 1g IV daily x7 days (antibiotics reduce mortality in variceal bleed)
- Restrictive transfusion: Hgb 7-8 (overtransfusion increases portal pressure)
- EGD within 12h for band ligation; nadolol for secondary prophylaxis
Teaching point: Do NOT correct INR with FFP, cirrhotic coagulopathy is rebalanced. FFP adds volume and worsens portal hypertension. Paracentesis is safe even with elevated INR.
📋 Case 3, Hepatorenal Syndrome
Patient: 55 y/o F with NASH cirrhosis, MELD-Na 28, Cr rising 1.2 → 3.8 over 5 days despite albumin challenge.
Key findings: UNa < 10, bland sediment, renal US normal. Albumin 1.5 g/kg x2 days with no Cr improvement. FENa 0.2%.
Management:
- HRS type 1 (rapid Cr rise, no response to albumin volume challenge)
- Midodrine 7.5 mg TID + octreotide 100 mcg TID + albumin 25-50g daily
- If refractory: norepinephrine drip (ICU) or terlipressin CONFIRM, 2021
- Transplant evaluation, definitive treatment (> 80% mortality without transplant)
Teaching point: HRS is a diagnosis of exclusion. The albumin challenge (1.5 g/kg x2 days) is both diagnostic and therapeutic. Avoid NSAIDs, aminoglycosides, and ACEi/ARBs in all cirrhotics.
📣 Sample Presentation
One-Liner
"Mr. Nguyen is a 56-year-old with alcohol-related cirrhosis, Child-Pugh C, MELD-Na 24, presenting with tense ascites and bilateral lower extremity edema. No fever, no confusion."
Key Points to Cover on Rounds
Chronic decompensated cirrhosis. Paracentesis: 4L drained, albumin 25g IV infused (replace 6-8g per liter if >5L). Fluid: PMN 120 (no SBP), culture sent. Diuretics: spironolactone 100 mg + furosemide 40 mg (100:40 ratio). Na-restricted diet (2g/day). Varices: on nadolol for secondary prophylaxis. HCC screening: US + AFP done last month -negative. Hepatology following. Transplant evaluation in progress -6 months sobriety confirmed. MELD-Na 24.
Monitoring Parameters
| Parameter | Frequency | Target / Action |
|---|---|---|
| Repeat paracentesis | At 48 hours | PMN should drop > 25% from baseline. If not improving → suspect resistant organism, secondary peritonitis, or wrong diagnosis. Broaden antibiotics and get CT abdomen. |
| BMP / Creatinine | Daily | HRS surveillance. Rising Cr despite albumin = hepatorenal syndrome → urgent nephrology + hepatology consult. Cr is the most important lab to trend. |
| Urine output | Strict I&Os | UOP < 0.5 mL/kg/hr or declining → early sign of HRS. Correlate with Cr trend. |
| Mental status | q4–8h | HE surveillance -SBP is the most common precipitant of hepatic encephalopathy. Worsening confusion → start/escalate lactulose. |
| Blood cultures | At diagnosis, repeat if persistent fever | Guide antibiotic narrowing once sensitivity data available. |
| Vitals | q4h | Fever curve, hemodynamics. Persistent fever > 72h on appropriate antibiotics → reconsider diagnosis. |
The 48-hour paracentesis is critical. If PMN count is not dropping > 25%, you need to reconsider: resistant organism (broaden coverage), secondary peritonitis (get CT), or bacterascites that resolved on its own.
⚡ Summary
Summary
Always Tap
Every new-onset ascites, every admission, and every clinical deterioration in a cirrhotic needs a diagnostic paracentesis. SBP is present in about 15% of cirrhotics admitted to hospital and is frequently asymptomatic, with no fever and no abdominal pain. You will miss it without tapping, and the mortality of missed SBP is high.
The INR Is Not a Contraindication
Cirrhotics are simultaneously auto-anticoagulated and auto-procoagulant; hemostasis is rebalanced, not simply impaired. Bleeding complications are under 1% even with an INR above 2 and platelets below 50,000. Do not transfuse plasma or platelets to correct numbers before a tap: it delays the diagnosis and does not reduce the (already minimal) risk.
Read the Fluid Properly
SAAG at or above 1.1 g/dL means portal hypertension; below 1.1 means something else (peritoneal carcinomatosis, tuberculosis, pancreatic ascites). PMN above 250/mm³ means SBP, treat regardless of symptoms, with a third-generation cephalosporin plus albumin (1.5 g/kg day 1, 1 g/kg day 3), which reduces hepatorenal syndrome and mortality. Send fluid for culture in blood culture bottles at the bedside, which markedly raises the yield. Multiple organisms or a high protein with low glucose suggests secondary peritonitis, which needs imaging and surgery, not just antibiotics.
Repeat the Tap at 48 Hours
The PMN count should fall by more than 25%. If it has not, reconsider: a resistant organism needing broader coverage, secondary peritonitis needing a CT, or bacterascites that has resolved on its own. This single repeat study catches the treatment failures that otherwise present as deterioration days later.
Treat Ascites With Salt and Diuretics
Sodium restriction to about 2 g/day plus spironolactone and furosemide in a 100:40 ratio, which keeps potassium stable. Fluid restriction only for a sodium below 125. Large-volume paracentesis for tense ascites, with albumin 8 g per liter removed above 5 liters to prevent post-paracentesis circulatory dysfunction. Stop NSAIDs entirely, since they cause diuretic resistance and renal failure.
Prevent Variceal Bleeding Deliberately
Screening endoscopy at diagnosis. Non-selective beta blocker (propranolol, nadolol or carvedilol) or band ligation for medium to large varices, titrating the beta blocker to heart rate rather than blood pressure. Hold beta blockers in refractory ascites, SBP and hepatorenal syndrome, where the loss of cardiac output reserve worsens renal perfusion. Acute bleeding: octreotide, antibiotic prophylaxis with ceftriaxone (which improves survival independently), and endoscopy within 12 h.
Stage It and Watch for Decompensation
Child-Pugh and MELD both stage severity; MELD drives transplant listing. The decompensation events are ascites, variceal bleeding, hepatic encephalopathy and jaundice, and the first of them marks a sharp fall in survival. Refer for transplant evaluation at first decompensation, not when the patient is moribund.
Do Not Forget the Surveillance and the Vaccines
Hepatocellular carcinoma screening with ultrasound every 6 months, with or without AFP: it is the surveillance that most often lapses and the one that finds curable disease. Vaccinate against hepatitis A and B, influenza and pneumococcus. Treat the cause, alcohol cessation, hepatitis C, weight loss in MASLD, since removing the driver can reverse decompensation. Nutrition matters: these patients are sarcopenic, need 1.2 to 1.5 g/kg/day of protein and a late evening snack, and should never be protein-restricted.
💊 Medications
Key Medications -Cirrhosis & Portal Hypertension
| Drug | Dose | Indication | Watch for |
|---|---|---|---|
| Lactulose 1ST LINE HE | 30 mL PO TID, titrated | Hepatic encephalopathy. Acidifies the colon so ammonia is trapped as ammonium and purged. | Titrate to 2 to 3 soft stools per day, not to a fixed dose. Overshooting causes dehydration and hypernatremia, which themselves precipitate encephalopathy. |
| Rifaximin | 550 mg PO BID | Added after a second episode of overt HE to prevent recurrence. | Minimal systemic absorption and well tolerated; cost is the main barrier. Used with lactulose, not instead of it. |
| Carvedilol (or propranolol, nadolol) | Carvedilol 6.25 mg daily, titrated | Non-selective beta-blockade for varices, primary and secondary prophylaxis. Carvedilol is generally preferred as it lowers portal pressure more. | Hold if systolic BP is below 90, in AKI, or in refractory ascites with hypotension, where NSBBs impair the compensatory response and worsen outcomes. |
| Spironolactone + furosemide | 100 mg : 40 mg, ratio maintained on uptitration | Ascites. Spironolactone is the backbone because the ascites is aldosterone-driven. | The ratio preserves potassium balance. Watch Na, K and creatinine. Stop diuretics in AKI, hyponatremia below 120, or encephalopathy. |
| Albumin 25% | 6 to 8 g per liter removed; 1.5 g/kg then 1 g/kg in SBP | After large-volume paracentesis over 5 L, in SBP, and as part of HRS treatment. | Prevents post-paracentesis circulatory dysfunction, and in SBP reduces renal failure and mortality. Give on day 1 and day 3 in SBP. |
| Ceftriaxone / cefotaxime | Ceftriaxone 1 to 2 g IV daily | SBP treatment, and short-course prophylaxis during variceal bleeding. | Diagnose SBP on an ascitic PMN count of 250 or more. Treat before the culture returns; cultures are negative in a substantial minority. |
| Octreotide | 50 mcg IV bolus, then 50 mcg/hr | Acute variceal bleeding, alongside antibiotics and endoscopy. | Splanchnic vasoconstriction reduces portal inflow. Continue for 3 to 5 days after control. |
| Terlipressin or midodrine + octreotide | With albumin in both cases | Hepatorenal syndrome (HRS-AKI). Terlipressin where available, otherwise midodrine plus octreotide. | Terlipressin carries a real risk of ischemic and respiratory complications; select patients carefully and monitor oxygenation. |
Drugs to avoid or dose with care in cirrhosis: NSAIDs (precipitate AKI and blunt diuretic response), aminoglycosides, and sedatives including benzodiazepines which both mask and worsen encephalopathy. Acetaminophen is acceptable at up to 2 g/day and is preferred over NSAIDs for analgesia.
📄 One Pager
Text version
GI / Hepatology · One Pager
Cirrhosis
Screen for HCC (US + AFP q6mo) and varices (EGD). Ascites: Na restrict + spironolactone/furosemide. Avoid NSAIDs, sedatives, aminoglycosides.
Decompensation Signs
Ascites, variceal bleed, HE, jaundice, SBP. Marks transition to decompensated cirrhosis -median survival drops significantly.
Ascites Management
Na restriction 2g/day. Spironolactone 100 + furosemide 40 (100:40 ratio). LVP + albumin for tense/refractory. TIPS if refractory (caution: worsens HE).
Screening
HCC: US + AFP every 6 months. Varices: EGD at diagnosis. Band ligation or BB (nadolol) for secondary prophylaxis. MELD-Na ≥ 15 → transplant referral.
Key Drugs
Spironolactone100-400 mg daily
Furosemide40-160 mg daily
Nadolol20-80 mg daily
Lactulose15-30 mL q2-4h (for HE)
Pitfalls
- NSAIDs (renal failure in cirrhotics)
- ACEi/ARBs (hypotension)
- Missing HCC screening
- Not doing diagnostic paracentesis for new ascites or clinical change
Related Topics
Acute Alcoholic HepatitisAcute Liver FailureAutoimmune HepatitisBowel ObstructionCholangitis & CholecystitisClostridioides difficile (C. diff)