Approach - Management of ascites in cirrhotic patients Dr . Khaled sheha
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Approach - Management of ascites
in cirrhotic patientsDr . Khaled sheha
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Causes of ascites
Causative disorders Percentage
Cirrhosis 85%
PHT-related disorder 8%
Cardiac disease 3%
Peritoneal carcinomatosis 2%
Miscellaneous non-PHT disorders 2%
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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.
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Ascites grade 1
Detectable only by US
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Pathogenesis of ascites in cirrhosisPHT
Nitric oxide
Vasodilatation
Renal Na retention
Ascites formation
Overfill of intravascular volume
Sympathetic activity RAA system
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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
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Needle-entry sitesNeedle-entry sites
.
Superior & inferior epigastric arteries run just lateral to theumbilicus towards mid-inguinal point & should be avoided
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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
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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
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What are the contraindications &
complications of paracentesis?
MA
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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 .
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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.
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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
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Serum Ascites Albumin Gradient (SAAG)
Albumin Serum – Albumin Ascites
(g/dL) (g/dL) in the same day
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Differential diagnosis according to SAAG
High Gradient ≥ 1.1 g/dL
Low Gradient < 1.1 g/dL
.
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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 .
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What is the treatment?
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Tapping ascitic fluid (1672)
German National Museum, Nürnberg, Germany
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What do you prescribe to this patient?
What are the side effects of these drugs?
How do you follow-up the patient?
ND
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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
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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
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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
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Follow-up of patients on diuretics – 2
• Body weight
• Blood pressure
• Pulse
• Electrolytes
• Urea
• Creatinine
Every 2 – 4 weeks
Every few months thereafter
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Side effects of diuretics• Spironolactone
Men libido, impotence, gynecomastiaWomen Menstrual irregularity
• Hydro-electrolytes disturbancesHypovolemia: hypotension – renal insufficiency HyponatremiaHypo or hyperkalemia Hepatic encephalopathy
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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
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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
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RecommendationBed rest
Bed rest is NOT necessary for the
treatment of cirrhotic ascites
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How do you treat the tense ascites in this patient?
OH
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Is this a refractory ascites?
How do you treat refractory ascites?
RA
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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
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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
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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.
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Treatment of refractory ascites
• Serial therapeutic paracentesis
• TIPS
• Liver transplantation
• Peritoneovenous shunt: LeVeen – Denver
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TIPS for refractory ascites
Is
practice guidelines Runyon BA. Hepatology 2004; 39: 841 – 856.
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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
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• 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
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