Bed rest and dietary Na restriction are the mainstays of therapy. A 20- to 40-mEq/day Na diet, although unpalatable, usually initiates diuresis within a few days and rarely causes serious electrolyte derangements. Diuretics should be used if rigid Na restriction fails. Spironolactone 100 to 300 mg/day po in two or three divided doses is usually effective without causing the marked K loss often associated with thiazides or related diuretics. If this proves insufficient, a thiazide or loop diuretic should be added (eg, hydrochlorothiazide 50 to 100 mg/day po or furosemide 40 to 160 mg/day po in divided doses). Fluid restriction is not needed unless serum Na is < 130 mEq/L. Changes in body weight and urinary Na determinations measure response to treatment. Weight loss of about 0.5 kg/day is optimum, as the ascitic compartment cannot be mobilized much more rapidly. Harsh diuresis produces fluid loss at the expense of the intravascular compartment, especially when peripheral edema is absent; this may cause renal failure or electrolyte imbalance (eg, hypokalemia) that may precipitate portal-systemic encephalopathy. Inadequate dietary Na restriction is the usual reason for persistent ascites.
Therapeutic paracentesis is an alternative approach. Removal of 4 to 6 L/day is safe, provided that salt-poor albumin (about 40 g/paracentesis) is concomitantly infused IV to prevent intravascular volume depletion. Even single total paracentesis appears safe. Therapeutic paracentesis shortens the hospital stay with relatively little risk of electrolyte imbalance or renal failure; nevertheless, patients require ongoing diuretics and tend to reaccumulate fluid more rapidly than those given traditional therapy.