How to manage fluid accumulation due to liver cirrhosis ?? (ASCITES)

How to treat ascites (water accumulation in abdomen) due to cirrhosis???

After discussing about bleeding let us discuss about water accumulation in the abdomen or ascites. – How to tackle??

Again I will mention guidelines given by American association of study of liver disease – which I found most evidence based.

Ascites is the most common of the 3 major complications of cirrhosis; the other complications are

hepatic encephalopathy and variceal bleeding. Approximately 50% of patients with ‘‘compensated’ ‘cirrhosis, i.e., without having developed one of these complications, develop ascites during 10 years of observation. Ascites is the most common complication

of cirrhosis that leads to hospital admission. Approximately 15% of patients with ascites succumb

in 1 year and 44% succumb in 5 years.

Ascitis is generally detected clinically and radiologically via ultrasonography or Ct scan.

How to manage patient with ascites??

1.     Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption.

2.     First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education,) and diuretics (oral spironolactone with or without oral furosemide).

3.     Fluid restriction is not necessary unless serum sodium is less than 125 mmol/L.

4.     An initial therapeutic abdominal paracentesis (removal of ascites fluid) should be performed in patients with tense ascites.(when huge accumulation and causing severe pain)

5.     Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses.

6.     The use of nonsteroidal anti-inflammatory drugs should be avoided in patients with cirrhosis and ascites, except in special circumstances.

7.     Liver transplantation should be considered in patients with cirrhosis and ascites.

Important messages from above posts are we are al advised to take less fluid when we are diagnosed with ascites however it is not necessary until our sodium is low. Ascitis should be removed inititally for diagnoses and then when abdomen is very full and causing much pain. Repeated removal of water is not necessary it may cause secondary infections.If you develop ascites, it indicates your liver has started to fail and you require evaluation by a liver transplant surgeon. Now let us see some more recommendations.

8.     The risks versus benefits of beta blockers must be carefully weighed in each patient with refractory ascites. Systemic hypotension often complicates their use. Consideration should be given to discontinuing or not initiating these drugs in this setting.

9.     Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L.

10.  For large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended

11.  Referral for liver transplantation should be expedited in patients with refractory ascites, if the patient is otherwise a candidate for transplantion.

12.  TIPS may be considered in appropriately selected patients.

Albumin is a costly injection it should be used only when you are removing more than 5 liters of fluid.However it is necessary when you are removing more than 5 liters of fluid.Like in case of bleeding TIPS has a role in selected patients with ascites also.

Spontaneous Bacterial Peritonitis: (SBP)

Ascitic fluid has high chances of secondary infection due to liver failure without any cause. It is known as spontaneous bacterial peritonitis. Whenever neutrophil contain of asctiis fluid is more than 250 cells it is diagnosed as spontaneous bacterial peritonitis and should be treated with antibiotics. When you develop SBP,SBP should be treated immediately and patient should be listed for transplant.

This was about how ascites should be treated when to remove fluid when not to when to give antibiotics, when to give albumin, tomorrow will discuss about another complication of liver disease hepatorenal syndrome.