Approach - Management of ascites in cirrhotic patients Dr . Khaled sheha
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Transcript of Approach - Management of ascites in cirrhotic patients Dr . Khaled sheha
Approach - Management of ascites
in cirrhotic patientsDr . Khaled sheha
Causes of ascites
Causative disorders Percentage
Cirrhosis 85%
PHT-related disorder 8%
Cardiac disease 3%
Peritoneal carcinomatosis 2%
Miscellaneous non-PHT disorders 2%
Diagnosis of ascites*
• Ascites can be graded asGrade 1 (mild) Detectable only by USGrade 2 (moderate) Moderate abdominal distensionGrade 3 (large) Marked abdominal distension
* Moore KP et al. Hepatology 2003 ; 38 : 258 – 66.
Ascites grade 1
Detectable only by US
Pathogenesis of ascites in cirrhosisPHT
Nitric oxide
Vasodilatation
Renal Na retention
Ascites formation
Overfill of intravascular volume
Sympathetic activity RAA system
Indications for diagnostic paracentesis• Patients with new-onset ascites
• Cirrhotic patients with ascites at admission
• Cirrhotic patients with ascites & symptoms or signsof infection: fever, leukocytosis, abdominal pain
• Cirrhotic patients with ascites & clinical conditiondeteriorating during hospitalization: renal functionimpairment, hepatic encephalopathy, GI bleeding
Needle-entry sitesNeedle-entry sites
.
Superior & inferior epigastric arteries run just lateral to theumbilicus towards mid-inguinal point & should be avoided
The Z-tract technique
Thomsen TW et al. N Engl J Med 2006 ; 355 : e21.
Green (21 G) or blue (23 G) needleDiagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
The angular insertion technique
.
Green (21 G) or blue (23 G) needleDiagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
What are the contraindications &
complications of paracentesis?
MA
Complications of paracentesis
• Abdominal hematomas Up to 1 % of patients Rarely serious or life threatening
• Hemoperitoneum or bowel perforation Rare (< 1/1000 procedures)
Serious complications
Guidelines on management of ascites in cirrhosis. Gut 2006 ; 55 ; 1 – 12 .
Contraindications to paracentesis
• Clinically evident fibrinolysis or DICPreclude paracentesis
• Abnormal coagulation profile Paracentesis not contraindicatedMajority of pts have prolonged PT & thrombocytopeniaNo data to support the use of FFP before paracentesis
AASLD practice guidelines Runyon BA. Hepatology 2004; 39: 841 – 856.
Ascitic Fluid Laboratory Data
Cell count *AlbuminTotal protein
CultureGlucoseLDHAmylaseGram’s stain
TB smear & cultureCytologyTGBilirubin
pHLactateCholesterolFibronectin
Routine Optional Unusual Unhelpful
.
* Automated counting can replace manual cell count
Serum Ascites Albumin Gradient (SAAG)
Albumin Serum – Albumin Ascites
(g/dL) (g/dL) in the same day
Differential diagnosis according to SAAG
High Gradient ≥ 1.1 g/dL
Low Gradient < 1.1 g/dL
.
Differential diagnosis of ascites according to SAAG
High Gradient ≥1.1 g/dL (11g/L)
Low Gradient <1.1 g/dL (11g/L)
Cirrhosis Peritoneal carcinomatosis
Liver metastases Tuberculous peritonitis
Cardiac ascites Pancreatic ascites
Portal-vein thrombosis Biliary ascites
Budd–Chiari syndrome Nephrotic syndrome
Hypothyroid Serositis .
What is the treatment?
Tapping ascitic fluid (1672)
German National Museum, Nürnberg, Germany
What do you prescribe to this patient?
What are the side effects of these drugs?
How do you follow-up the patient?
ND
Dietary salt should be restricted to a no-added
salt diet of 90 mmol salt/day (5.2 g salt/day) by
adopting a no-added salt diet & avoidance of
pre-prepared foodstuffs
RecommendationLow sodium diet
ND
Diuretics treatment in cirrhotic ascitesOral route – Single morning dose
Progressive Schedule Combined Schedule
SP * 100 200 300 400 mg/d
SP 400 mg/d + FUR**40 80 120 160 mg/d
SP 100 mg/d+ FUR 40 mg/d
SP 200 300 400 mg/d+ FUR 80 120 160 mg/d
Progressive increase every 3-5 days
*SP Spironolactone**FUR Furosemide
Follow-up of patients on diuretics – 1
• Weight lossMassive edema No limit to daily weight lossResolved edema 0.5 kg / day
• Weight loss less than desired24-hour urine sodium > 78 mmol/24h & no weight loss: patient not compliant
< 78 mmol/24h & no weight loss: increased diuretics“spot” urine NA/K>1= 24-hour urine Na>78 mmol/24h
Follow-up of patients on diuretics – 2
• Body weight
• Blood pressure
• Pulse
• Electrolytes
• Urea
• Creatinine
Every 2 – 4 weeks
Every few months thereafter
Side effects of diuretics• Spironolactone
Men libido, impotence, gynecomastiaWomen Menstrual irregularity
• Hydro-electrolytes disturbancesHypovolemia: hypotension – renal insufficiency HyponatremiaHypo or hyperkalemia Hepatic encephalopathy
Water restriction
• Not necessary in most cirrhotic patients with ascites
• Cirrhotic patients have symptoms from hyponatremiaif Na < 110 mmol/L or if very rapid decline in Na
• Water restriction indicated in patients who are clinicallyeuvolaemic withs severe hyponatraemia & not takingdiuretics with normal creatinine
• Avoid increasing serum sodium > 12 mmol/l per day
ND
Bed rest in cirrhotic ascites
• Upright posture associated with activation of RAA
system, reduction in GFR & sodium excretion, &
decreased response to diuretics
• Bed rest muscle atrophy & other complications
• No clinical studies to demonstrate efficacy of bed rest
RecommendationBed rest
Bed rest is NOT necessary for the
treatment of cirrhotic ascites
How do you treat the tense ascites in this patient?
OH
Is this a refractory ascites?
How do you treat refractory ascites?
RA
Refractory ascites ( 10 %)
• Diuretic resistant ascitesUnresponsive to LSD (< 88 mmol/day)& High-dose diuretics SP 400 mg & FUR 160 mg/d
• Diuretic intractable ascitesDiuretic induced complications Encephalopathy Creatinine > 2.0 g/dL Na < 125 mmol/L K > 6 or < 3 mmol/L
International ascites clubArroyo V et al. Hepatology 1996 ; 23 : 164 – 76.
for at least 1 week
RecommendationsTreatment of refractory ascites
• Therapeutic paracentesis is the first line treatment: < 5 L: Colloid - No need for albumin
> 5 L: Albumin after paracentesis (8g/l)
• TIPS should be considered in refractory ascites
• LT referral should be considered in refractory ascites
• Peritoneovenous shunt should be considered in patientswho are not candidates for paracentesis, TIPS, or LT
ND
Refractory Ascites
LT evaluationLVP + Albumin
Na restricted diet (90 mEq/d)Fluid restriction if Na < 130 mEq/L
Repeated LVP + albumin
Preserved liver function?Loculated ascites?
Paracentesis more frequent than 2-3 /month?
Continue LVP + Albumin
Consider TIPS
1st Step
MaintenanceTreatment
YesNo
Clin Gastroenterol Hepatol 2005 ; 3 : 1187 – 1191.
Treatment of refractory ascites
• Serial therapeutic paracentesis
• TIPS
• Liver transplantation
• Peritoneovenous shunt: LeVeen – Denver
TIPS for refractory ascites
Is
practice guidelines Runyon BA. Hepatology 2004; 39: 841 – 856.
Albumin in cirrhotic ascites• Large paracentesis > 5 L
8 g albumin/liter of ascites removed(100 ml of 20% albumin / 3 L ascites)
• SBP with renal impairementFirst six hours 1.5 g albumin / kg bw Day 3 1g albumin / kg bw
• HRS-IFirst day 1 g / kg bw (maximum 100 g) Following days 20 – 40 g / day
• Ascites 50 % survival at 2 years• Refractory ascites50% survival at 6 months
25% survival at 1 year• SBP 30 - 50% survival at 1 year• HRS-2 40% survival at 6 months• HRS-1 < 5% survival at 6 months
Prognosis of ascites in cirrhotic patients
Referral to liver transplantation unit