Ascites

 

Ascites in cirrhosis of liver 

– 50% cirrhosis patient will develop ascites within 10 years

– 50% patients of ascites in cirrhosis will die within 2 years

– Development of ascites in a patient with cirrhosis should prompt referral for liver transplantation

– 1500 ml of fluid is required to detect clinically

– USG can detect as little as 100 ml of ascites

– Long standing ascites may cause umbilical

Grading of ascites and treatment:  

 

Uncomplicated ascites

  • – 75% of patients presenting with ascites have cirrhosis as the underlying cause
  • – Other causes are: Tuberculosis, malignancy, heart failure, pancreatic disease or other miscellaneous cause

Who should undergo diagnostic paracentesis?

  • – All patients with new onset grade 2 or 3 ascites
  • – All patients hospitalized for worsening of ascites or any complication of ascites

Cirrhotic patients with ascites are at risk for complications of

  • – Refractory ascites
  • – SBP
  • – Hyponatremia
  • – Hepatorenal syndrome (HRS)

Management of Ascites

Management of Grade-2 ascites:

  •           – Do not require hospitalization unless they have other complication of cirrhosis
  •          – Moderate salt restriction (Sodium intake 80-120 mmol/day corresponding to 4.6- 6.9 gm salt/day). This is equivalent to a no added salt diet with avoidance of pre-prepared meals
  •          – Fluid intake should be restricted only in patients with dilutional hyponatremia

Patient of first episode of ascites (grade-2)

    • – Spironolactone 100mg/day
    •            ↓
    • Increase the dose stepwise manner every 7 day upto 400mg/day if no response
    • – Amiloride, a diutretic acting in the collecting duct, is less effective than aldosterone antagonist and should be used only in patients who develop severe side effects with aldosterone antagonist
    • -Definition of patient unresponsive to aldosterone antagonist: Reduction of body weight <2kg/week
    • – Patient who is unresponsive to aldosterone antagonist or patient who develop hyperkalemia, furosemide should be added at an increasing stepwise dose from 40mg/day to a maximum of 160mg/day
    • – Patient should undergo frequent clinical and biochemical monitoring particularly during the first month of therapy
    • – Once the ascites has largely resolved, the dose of diuretics should be reduced and discontinued later, whenever possible

Patient with recurrent ascites

    Combination of Aldosterone antagonist + Frusemide

Increase the dose of both drugs every 7 day according to the response

The maximum recommended weight loss during diuretic therapy:

    • → 0.5 kg/day – if no edema
    • → 1 kg/day – if peripheral edema

Contraindication of diuretic:

– Hepatic encephalopathy

All diuretics should be discontinued if there is:

– Severe hyponatremia(S. Na<120 mmol/L)

– Progressive renal failure

– Worsening hepatic encephalopathy

– Incapacitating muscle cramp

-Furosemide should be discontinued if there is severe hypokalemia (<3 mmol/L)

–  Aldosterone antagonists should be discontinued if there is severe hyperkalemia (>6 mmol/L)

Management of Grade-3 ascites:

  • – Large volume paracentesis (LVP) is the first line therapy
  • – LVP should be completed in a single session
  • – LVP together with administration of albumin ( 8g/L ascetic fluid removed) to prevent circulatory dysfunction after LVP
  • – After LVP, patients should receive minimum dose of diuretics necessary to prevent re-accumulation of ascites

** Diuretics increases opsonic activity of ascites 10 fold and theoretically may be of value in preventing SBP

 

  • Drugs contraindicated in cirrhotic ascites:
  •      – NSAID (  ↑risk of ARF, hyponatremia, diuretic resistance)
  •      –  ↓GFR due to reduced perfusion secondary to inhibition of renal prostaglandin synthesis)
  •      – ACE inhibitor, angiotensin receptor II antagonist (induce arterial hypotension, renal failure)
  •      – α-1 blocker
  •      – Dipyridamol should be used with caution (induce renal impairement)
  •      – Aminoglycoside alone or in combination of ampicillin, cephalothin, mezlocillin
  •      – Contrast media should be used with caution and general preventive measures of renal impairment is recommended

 

Diuretic-resistant ascites:

  • – Ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of a lack of response to sodium restriction and diuretic treatment

Diuretic-resistant ascites:

  • – Ascites that cannot be mobilized or early recurrence of which cannot be prevented because of the development of the diuretic induced complications that precludes the use of an effective diuretic dosage

Refractory ascites:

  • – Ascites that cannot be mobilized or the early recurrence of which (after LVP) cannot be satisfactorily prevented by medical therapy
  • Requisites for refractory ascites diagnosis:
  •          1.Treatment duration: patient must be on intensive diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) for at least 1 week and on a salt restricted diets of <90 mmol/day
  •          2.Lack of response: Mean weight loss <0.8 kg over 4 days and urinary sodium < sodium intake
  •         3.Early ascites recurrence: Reappearance of grade 2 or 3 ascites within 4 weeks of initial mobilization
  •         4.Diuretic induced complications Renal impairment, hyponatremia, hypo/hyperkalemia

Treatment of Refractory ascites:

  • 1) Large volume paracentesis with albumin administration (8 gm albumin for each litre of ascitic fluid removal)
  • 2) Continuing diuretic therapy (if effective in inducing natriuresis Urinary Na+ > 30 mmol/day
  • 3)  TIPS
  • 4) Liver transplantation
  • Diuretics in refractory ascites:
  •  – Though refractory ascites is by definition refractory to diuretic it should be continued in refractory ascites except in following situation
  •     1. Diuretic induced complications
  •                  • Hepatic encephalopathy
  •                  • Renal impairment
  •                  •Electrolyte abnormalities
  •       2.Urinary sodium excretion <30 mmol/day
  • Indications of TIPS in refractory ascites:
  •               – Very frequent requirement of LVP
  •               – Paracentesis is ineffective
  •              – Resolution of ascites after TIPS is slow and most patients require continued administration of diuretics  and salt restriction
  • Contra-indications of TIPS:
  •              – Severe liver failure
  •              – Bilirubin >5 mg/dl
  •              – CTP> C
  •             – Chronic hepatic encephalopathy
  •             – Concomitant infection
  •            – Progressive renal failure
  •            – Severe cardiopulmonary disease

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