A cirrhotic patient (Child-Pugh B) develops ascites. He is treated with spironolactone and furosemide. After 8 weeks, ascites persists despite doses of spironolactone 400 mg/day and furosemide 160 mg/day. Serum creatinine is rising. What is the next best step?

• A Increase spironolactone to 600 mg/day
• B Start rifaximin for spontaneous bacterial peritonitis prophylaxis
• C Initiate haemodialysis for worsening creatinine
• D Perform large-volume paracentesis (LVP) with concomitant albumin infusion (6-8 g/L ascites removed) ✓

Explanation

This patient has refractory ascites — defined as ascites that recurs rapidly after LVP or cannot be controlled with maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg/day) or diuretic-intractable ascites with complications. The recommended management is serial large-volume paracentesis (LVP) with simultaneous albumin infusion (6-8 g per litre of ascites removed) to prevent post-paracentesis circulatory dysfunction (PPCD/spontaneous hepatic encephalopathy). TIPS (transjugular intrahepatic portosystemic shunt) is an alternative for selected patients. Increasing diuretics beyond maximum doses risks AKI. Rifaximin prevents hepatic encephalopathy, not ascites.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.