Initial management consists of bed-rest, reduced salt intake, and spironolactone (50-100 mg per day). A fall in weight of approximately 0.5 kg per day should be aimed for.
If the above measures do not produce a weight reduction then spironolactone is gradually increased to 300 mg per day and then, if necessary, frusemide is added, but only once the spironolactone has reached its maximum dose.
There is a danger that the addition of loop diuretics may precipitate the hepatorenal syndrome; sodium supplements are contraindicated because the total body sodium is excessive in cirrhosis so the hyponatraemia is treated by water restriction or mannitol infusion (which increases free water excretion). If this approach is successful then the patient will require a maintenance dose of spironolactone (50-200 mg/day) and a restricted salt diet.
If a patient has malignant ascites then large doses of frusemide may be required to control ascites.
A Le Veen shunt (peritoneo-venous) may be useful in refractory cases.
If ascitic fluid contains more than 250 WBC per cubic millimetre then empirical treatment with a non-nephrotoxic broad spectrum antibiotic should be commenced.
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