Hepatitis Central

"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 ascites eliminates the patient's risk for such life threatening complications such as spontaneous bacterial peritonitis and hepatorenal syndrome and improves patient well-being. Refractory ascites is defined as ascites 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 ascites fall in this category. Non-compliance with sodium restriction is a major and often overlooked cause of refractory ascites. Therefore, the management of refractory ascites should begin with counselling regarding sodium restriction.

Compliance with sodium restriction will reduce the frequency of ascites recurrence. Repeated large volume paracentesis is a safe and effective means of controlling refractory ascites. 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 ascites. 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 ascites, 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 ascites formation in cirrhosis should lead to better understanding of the pathogenetic mechanisms and improved management of these patients.

Refractory Ascites: Definition:

Prolonged history of ascites 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 82mm Hg

Urinary sodium excretion 1.5mEq/day

Glomerular filtration rate 50mL/min

Plasma norepinephrine 570pg/mL

Nutritional status Poor

Hepatomegaly Present

Serum albumin 28g/L

Peritoneovenous Shunting:

Selection Criteria:

Serum bilirubin 60mmol/L

Prothrombin time 4 seconds prolonged

Platelet count 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 ascites. 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 ascites. 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 ascites 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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