A 52-year-old man with Child-Pugh B cirrhosis from alcohol (abstinent 8 months) develops worsening ascites and peripheral edema. Paracentesis shows SAAG 1.8 g/dL. He is started on spironolactone 100 mg and furosemide 40 mg daily. After 5 days, he is not losing weight and ascites persists. Serum creatinine is stable at 1.0 mg/dL, and serum potassium is 4.2 mEq/L. The next step is:

• A Switch to terlipressin for renal vasoconstriction
• B Initiate TIPS (transjugular intrahepatic portosystemic shunt)
• C Perform large-volume paracentesis immediately
• D Increase spironolactone to 400 mg and furosemide to 160 mg (maintaining 100:40 ratio) ✓

Explanation

EASL guidelines recommend stepwise increase of spironolactone and furosemide maintaining the 100:40 mg ratio (to preserve normokalemia) up to maximum doses of 400 mg/160 mg per day before considering refractory ascites. Response should be assessed over 7–10 days (target weight loss ≥500 g/day if no peripheral edema, or ≥1 kg/day if peripheral edema present). TIPS is reserved for refractory ascites (failure of maximum diuretic doses or diuretic intolerance). LVP is used for tense or symptomatic ascites not responding to diuretics, not as initial escalation.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.