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 as

Grade 1 (mild) Detectable only by US

Grade 2 (moderate) Moderate abdominal distension

Grade 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 cirrhosisPHTPHT

Nitric oxide Nitric oxide

VasodilatationVasodilatation

Renal Na retentionRenal Na retention

Ascites formationAscites formation

Overfill of intravascular volume

Overfill of intravascular volume

Sympathetic activity RAA system

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 signs

of infection: fever, leukocytosis, abdominal pain

• Cirrhotic patients with ascites & clinical condition

deteriorating during hospitalization: renal function

impairment, hepatic encephalopathy, GI bleeding

Needle-entry sitesNeedle-entry sites

.

Superior & inferior epigastric arteries run just lateral to the

umbilicus 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) needle

Diagnostic 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) needle

Diagnostic 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 DIC

Preclude paracentesis

• Abnormal coagulation profile

Paracentesis not contraindicated

Majority of pts have prolonged PT & thrombocytopenia

No 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 *

Albumin

Total protein

Culture

Glucose

LDH

Amylase

Gram’s stain

TB smear & culture

Cytology

TG

Bilirubin

pH

Lactate

Cholesterol

Fibronectin

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

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

Recommendation

Low 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 loss

Massive edema No limit to daily weight loss

Resolved edema 0.5 kg / day

• Weight loss less than desired

24-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, gynecomastia

Women Menstrual irregularity

• Hydro-electrolytes disturbances

Hypovolemia: hypotension – renal insufficiency

Hyponatremia

Hypo or hyperkalemia

Hepatic encephalopathy

Water restriction

• Not necessary in most cirrhotic patients with ascites

• Cirrhotic patients have symptoms from hyponatremia

if Na < 110 mmol/L or if very rapid decline in Na

• Water restriction indicated in patients who are clinically

euvolaemic withs severe hyponatraemia & not taking

diuretics 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

Recommendation

Bed 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 ascites

Unresponsive to LSD (< 88 mmol/day)

& High-dose diuretics

SP 400 mg & FUR 160 mg/d

• Diuretic intractable ascites

Diuretic 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 patients

who 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 impairement

First six hours 1.5 g albumin / kg bw

Day 3 1g albumin / kg bw

• HRS-I

First 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