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Intractable Ascites

Florence Wong, MD, GI Division, Department of Medicine, University of Toronto,
The Toronto Hospital

Abstract:

Ascites is a common complication of liver cirrhosis. Its presence indicates
a poor prognosis. Effective management of eliminates the patient’s risk
for such life threatening complications such as spontaneous bacterial peritonitis
and hepatorenal syndrome and improves patient well-being. Refractory
is defined as unresponsive to 400 mg of spironolactone or 30 mg of amiloride
plus up to 160 mg of furosemide daily for two weeks. Patients who cannot tolerate
diuretics because of side effects are also regarded as diuretic resistant. Approximately
15% of all patients with fall in this category. Non-compliance with
sodium restriction is a major and often overlooked cause of refractory .
Therefore, the management of refractory should begin with counselling
regarding sodium restriction.

Compliance with sodium restriction will reduce the frequency of recurrence.
Repeated large volume paracentesis is a safe and effective means of controlling
refractory . Single large volume paracentesis can be safely performed
without the infusion of plasma expanders such as albumin. However, patients
who require frequent repeated large volume paracentesis or a single total paracentesis
should receive albumin infusion. A peritoneovenous shunt is a device that returns
ascitic fluid from the peritoneal cavity to the systemic circulation. Its use
is restricted to patients with well preserved hepatic function since survival
following peritoneovenous shunting falls off dramatically in patients with severe
liver dysfunction. The associated complications, including technical problems,
makes this an option for only selected patients. The advent of a transjugular
intrahepatic portosystemic stent shunt (TIPS) allows a non surgical means of
decompressing the portal circulation without the high morbidity and mortality
associated with surgically created shunts. Ascites gradually disappears after
TIPS insertion, especially in the absence of diuretic therapy. Sodium restriction
therefore is still required even after TIPS insertion for effective elimination
of . Like peritoneovenous shunting, survival after TIPS insertion is
also related to the severity of liver function. Complications include potential
worsening of hepatic encephalopathy and the hyperdynamic circulation. It therefore
is not recommended for patients with pre-existing encephalopathy or cardiac
dysfunction.

Frequent TIPS occlusion demands careful follow-up. Liver transplantation should
be considered for all cirrhotic patients with refractory , and it should
be performed before the development of renal dysfunction, since the worst prognostic
indicator for morbidity and mortality after liver transplantation is renal impairment.
Continued research into the pathophysiology of formation in cirrhosis
should lead to better understanding of the pathogenetic mechanisms and improved
management of these patients.

Refractory Ascites: Definition:

Prolonged history of unresponsive to 400mg of spironolactone or 30mg
of amiloride plus up to 120mg of furosemide daily for 2 weeks.

Patients who cannot tolerate diuretics because of side effects are also regarded
as diuretic resistant.

Management of Refractory Ascites:

Repeat paracentesis

Peritoneovenous (LeVeen) shunt

Transjugular intrahepatic portasystemic stent shunt (TIPSS)

Poor Prognostic Indicators of Survival in Cirrhotic Patients with Ascites:

Mean arterial pressure Less Than 82mm Hg

Urinary sodium excretion Less Than 1.5mEq/day

Glomerular filtration rate Less Than 50mL/min

Plasma norepinephrine Great Than 570pg/mL

Nutritional status Poor

Hepatomegaly Present

Serum albumin Less Than28g/L

Peritoneovenous Shunting:

Selection Criteria:

Serum bilirubin Less Than 60mmol/L

Prothrombin time Less Than 4 seconds prolonged

Platelet count Great Than 50 x 106/L

Relative Contraindications:

Previous abdominal surgery

Spontaneous bacterial peritonitis

Large esophageal varices

TIPPS: Patient Selection:

Absolute contraindications:

Hepatic encephalopathy

Cardiac disease

Renal dysfunction

Non compliance with sodium and fluid restriction

Relative contraindications:

Dental sepsis

Spontaneous bacterial peritonitis

References:

1. D’Amico G, Morabito A, Pagliaro L, Marubini E. Survival
and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis
Sci 1986;31:468-75.

2. Runyon BA. Care of patients with . New Engl
J Med 1994;330:337-42.

3. Gines P, Arroyo V, Quintero E, et al. Comparison of
paracentesis and diuretics in the treatment of cirrhosis with tense .
Results of a randomized study. Gastroenterology 1987;93:234-41.

4. Runyon BA. Patient selection is important in studying
the impact of large-volume paracentesis on intravascular volume. Am J Gastro
1997;92:371-3.

5. Wong F, Blendis LM. Peritoneovenous shunting in cirrhosis:
its role in the management of refractory in the 1990’s. Am J Gastroenterol
1995;90:2086-9.

6. Wong F, Sniderman K, Liu P, Blendis LM. The mechanism
of the initial natriuresis after transjugular intrahepatic portosystemic shunt.
Gastroenterology 1997;112:899-907.

7. Wong F, Blendis LM. The patient with renal insufficiency.
Liver Transplantation and Surg 1996;2(Suppl 1):35-43.

Update On Liver Disease & Hepatitis Conference June
4 – 8, 1997

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