Ascites & SBP
Diagnostic tap on every admission with ascites. SAAG ≥1.1 = portal hypertension. High protein >2.5: cardiac, Budd-Chiari; low protein: cirrhosis.
Julia Cohn5 min6 questions2 trials
Tap every admission — then SAAG
Most common cirrhosis complication (50% in 10 ). New ascites: 15% 1-year and 44% 5-year mortality (: ; AGA: ). Portal pressure >12 mmHg → NO / prostaglandins / glucagon → splanchnic vasodilation → low effective arterial blood volume → RAAS / ADH → Na and water retention. Dilutional hyponatremia tracks survival.
- Send cell count with differential, albumin, total protein, Gram stain/culture. Add glucose, LDH, amylase, TG, bilirubin, cytology when the story is not straightforward.
- Traumatic tap: subtract 1 PMN per 250 RBCs if RBC >50,000/mm³.
| SAAG | Physiology | Then use protein |
|---|---|---|
| ≥1.1 g/dL | Portal hypertension () | AFTP <2.5: cirrhosis. AFTP >2.5: cardiac / constrictive / Budd-Chiari. Also acute hepatitis, ALF, HCC/massive mets, PVT |
| <1.1 g/dL | Not portal hypertension | TB, carcinomatosis (cytology+), chylous (TG >200), nephrosis / PLE / malnutrition (protein <2.5), serositis, pancreaticobiliary leak, secondary peritonitis |
Diuretics, salt, and large-volume taps
- Na <2 g/d. Fluid-restrict 1–1.5 L only if Na <125. Stop alcohol, NSAIDs, ACE inhibitors/ARBs; stop antihypertensives if MAP <82.
- Start spironolactone 100 mg + furosemide 40 mg every morning (5:2 keeps potassium near even). Spironolactone alone is reasonable for mild first ascites as an outpatient — never furosemide alone.
- Up-titrate q3–5 days. Max 400 / 160 mg. Eplerenone or amiloride if gynecomastia (weaker). UNa/UK <1 on full doses = ineffective diuretic or resistance; >1 = they are eating >2 g Na. Spot UNa 50–70 after the diuretic = adequate natriuresis.
- Weight-loss goals: 0.5 kg/d without edema (faster risks AKI); 1 kg/d with edema. Avoid IV diuretics. Ascites itself mobilizes at ~0.5 L/day ().
- Long-term weekly albumin may help uncomplicated outpatients () but targeting albumin >3 in decompensated inpatients did not (). SGLT2i may ascites.
- Refractory (~10%): unresponsive to salt restriction + max diuretics (or intolerant), or rapid reaccumulation. Exclude PVT and HCC. Stop diuretics if UNa <30 mEq/day; stop beta-blockers (↑ mortality; ); midodrine; serial LVP <8 L ~q2 weeks; TIPS if LVP-intolerant (poor candidate if MELD >18, Child C, heart failure, severe HE); tunneled catheters at end of life.
- Refractory anasarca is a transplant conversation regardless of MELD.
SBP — PMN ≥250, then SORT albumin
10–30% of hospitalized cirrhotics with ascites have SBP. Pain, tenderness, ileus, HE, or AKI — or nothing. PMN ≥250 with a positive culture is SBP; culture-negative neutrocytic ascites has similar mortality and is treated the same (: ).
SBP
- Usually monomicrobial: GNR 70% (E. coli, Klebsiella), GPC 25% (S. pneumoniae), anaerobes 5%.
- Community: ceftriaxone 2 g q24 h × 5 days (ciprofloxacin 400 mg IV q12 if cephalosporin-allergic and not already on cipro prophylaxis).
- Nosocomial / MDRO risk: pip-tazo + daptomycin (VRE) or meropenem if known MDRO or recent pip-tazo.
- Hold NSBBs in hospital; restart after recovery.
- Repeat tap at 48 h. Failure = PMN drop <25%.
Secondary peritonitis
- Polymicrobial, very high PMN, protein high, glucose low, LDH high.
- Worry about perforation if ≥2 of: total protein >1, LDH >ULN, glucose <50.
- This is a surgical / source-control problem, not a 5-day ceftriaxone problem.
- GI-bleed prophylaxis: ceftriaxone 1 g q24 h × 5 days.
- Secondary prophylaxis after SBP: ciprofloxacin 500 mg daily or TMP-SMX DS daily. Resistance is rising and effectiveness data are mixed (; : ).
- Primary prophylaxis: ascitic protein <1.5 plus (Cr ≥1.2 or BUN ≥25 or Na ≤130) or (Child ≥9 and bilirubin ≥3).