In fact, ascites is actually the most common complication of liver cirrhosis. . for 1 L of ascitic fluid removed, while the American Association for the Study of Liver. Sep 18, The presence of ascites indicates that cirrhosis has changed from .. European Association for the Study of the Liver () EASL clinical. Aug 13, The management of ascites in adults with cirrhosis is also discussed in a guideline from the American Association for the Study of Liver.
General ascites management in all patients should include minimizing consumption of alcohol, nonsteroidal anti-inflammatory drugs NSAIDsand dietary sodium. The use of more-aggressive interventions largely depends on the severity of ascites and includes oral diuretics, therapeutic or large-volume paracentesis, transjugular intrahepatic portosystemic shunt TIPSand orthotopic liver transplantation Figure 1.
Low-Volume Ascites All patients with cirrhotic ascites should be encouraged to minimize consumption of alcohol.
Even if alcohol is not the cause of their liver disease, cessation can lead to decreased fluid and improved response to medical therapies. Patients with ascites should also minimize use of all NSAIDs; these agents inhibit the synthesis of renal prostaglandin and can lead to renal vasoconstriction, decreased diuretic response, and acute renal failure.
Because fluid passively follows sodium, a salt restriction without a fluid restriction is generally all that is required to decrease the amount of ascites.
In patients with minimal fluid, the restriction of alcohol, NSAIDs, and salt may be all that is needed to control ascites formation adequately. Moderate-Volume Ascites Patients with moderate fluid overload who do not respond to more conservative measures should be considered for pharmacologic therapy.
A rapid reduction of ascites is often accomplished simply with the addition of low-dose oral diuretics in the outpatient setting. First-line diuretic therapy for cirrhotic ascites is the combined use of spironolactone Aldactone and furosemide Lasix. Beginning dosages are mg of spironolactone and 40mg of furosemide by mouth daily. If weight loss and natriuresis are inadequate, both drugs can be simultaneously increased after 3 to 5 days to mg of spironolactone and 80 mg of furosemide.
To maintain normal electrolyte balance, the use of the The response to diuretics should be carefully monitored on the basis of changes in body weight, laboratory tests, and clinical assessment.
Patients on diuretics should be weighed daily; the rate of weight loss should not exceed 0. Serum potassium, blood urea nitrogen BUNand creatinine levels should be serially followed. In the event of marked hyponatremia, hyperkalemia or hypokalemia, renal insufficiency, dehydration, or encephalopathy, diuretics should be reduced or discontinued. Routine measurement of the urinary sodium level is not necessary, but it can be helpful to identify noncompliance with dietary sodium restriction.
If not, they are noncompliant with their diet and should be referred to a dietician. The spot urine sodium-to-potassium ratio might ultimately replace the cumbersome hour collection: Because of the potentially severe complications associated with diuretic use, patients with ascites should be assessed by a health care provider at least once weekly until they are clinically stable. Large-Volume Ascites Large-volume ascites is defined as intraperitoneal fluid in an amount that significantly limits the activities of daily life.
Ascites: A Common Problem in People with Cirrhosis | ACG Patients
With additional fluid retention, the abdomen can become progressively distended and painful. This infection is common among people with ascites and cirrhosisespecially alcoholics.
If spontaneous bacterial peritonitis develops, people usually have abdominal discomfort, and the abdomen may feel tender. People may have a fever and feel generally unwell. They may become confused, disoriented, and drowsy. Untreated, this infection can be fatal.
Survival depends on early treatment with appropriate antibiotics. Diagnosis Sometimes an imaging test such as ultrasonography Sometimes analysis of ascitic fluid When a doctor taps percusses the abdomen, the fluid makes a dull sound.
If the person's abdomen is swollen because the intestines are distended with gas, the tapping makes a hollow sound. However, a doctor may not be able to detect ascitic fluid unless the volume is about a quart or more.
If doctors are uncertain whether ascites is present or what is causing it, they may do ultrasonography or computed tomography CT see Imaging Tests of the Liver and Gallbladder. In addition, a small sample of ascitic fluid can be withdrawn by inserting a needle through the wall of the abdomen—a procedure called diagnostic paracentesis. Laboratory analysis of the fluid can help determine the cause. Treatment A low-sodium diet and bed rest Diuretics Removal of ascitic fluid therapeutic paracentesis Sometimes surgery to reroute blood flow portosystemic shunting or liver transplantation For spontaneous bacterial peritonitis, antibiotics The basic treatment for ascites is a low-sodium diet.
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If diet is ineffective, people are usually also given drugs called diuretics such as spironolactone or furosemide. Diuretics make the kidneys excrete more sodium and water into the urine so people urinate more.
If ascites becomes uncomfortable or makes breathing or eating difficult, the fluid may be removed through a needle inserted into the abdomen—a procedure called therapeutic paracentesis.
The fluid tends to reaccumulate unless people also follow a low-sodium diet and take a diuretic. Because a large amount of albumin is usually lost from the blood into the abdominal fluid, albumin may be given intravenously.
If large amounts of fluid accumulate frequently or if other treatments are ineffective, a portosystemic shunt or liver transplantation may be needed. The portosystemic shunt connects the portal vein or one of its branches with a vein in the general circulation and thus bypasses the liver.