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 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.
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Ascites grade 1
Detectable only by US
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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
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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 signs
of infection: fever, leukocytosis, abdominal pain
• Cirrhotic patients with ascites & clinical condition
deteriorating during hospitalization: renal function
impairment, hepatic encephalopathy, GI bleeding
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Needle-entry sitesNeedle-entry sites
.
Superior & inferior epigastric arteries run just lateral to the
umbilicus 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) needle
Diagnostic 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) needle
Diagnostic 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 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.
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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
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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
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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
Recommendation
Low 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 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
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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, gynecomastia
Women Menstrual irregularity
• Hydro-electrolytes disturbances
Hypovolemia: hypotension – renal insufficiency
Hyponatremia
Hypo or hyperkalemia
Hepatic encephalopathy
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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
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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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Recommendation
Bed 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 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
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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 patients
who 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 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
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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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