A 52-year-old man with alcohol-related liver cirrhosis (Child-Pugh C) develops increasing abdominal girth. Ascitic fluid analysis: protein 12 g/L, SAAG 1.5 g/dL, WBC 80 cells/mm³ with 30% neutrophils. No spontaneous bacterial peritonitis. The FIRST-LINE treatment for ascites management is:
- A Spironolactone 100 mg plus furosemide 40 mg in a 100:40 ratio, titrated ✓
- B Spironolactone alone 400 mg/day
- C Furosemide alone 160 mg/day
- D Large-volume paracentesis as first-line regardless of kidney function
Correct answer: A. Spironolactone 100 mg plus furosemide 40 mg in a 100:40 ratio, titrated
Explanation
First-line management of cirrhotic ascites per EASL/AASLD guidelines is combination diuretic therapy using spironolactone (aldosterone antagonist) plus furosemide in a 100:40 mg ratio to maintain normokalemia. This ratio can be titrated together up to 400:160 mg. Spironolactone alone is slower and may cause hyperkalemia; furosemide alone risks hyponatremia and hypokalemia. Large-volume paracentesis is used for refractory ascites or tense ascites causing discomfort.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.