Cirrhotic Ascites

Aka: Cirrhotic Ascites, Hepatic Ascites

1. See Also
   1. Ascites
   2. Ascites Causes
   3. Cirrhosis
2. Epidemiology
   1. Most common complication of Cirrhosis
      1. Presents in 60% of patients within 10 years of Cirrhosis diagnosis
3. Pathophysiology
   1. Portal Hypertension
      1. Results in increased splanchnic Blood Volume with increased nitric oxide production
      2. Secondary splanchnic and arterial vasodilation
   2. Kidneys sense decreased perfusion
      1. Activates Renin-Angiotensin System
      2. Results in increased Sodium and water retention
   3. Hypoalbuminemia and decreased oncotic pressure
      1. Increased splanchnic pressure overcomes oncotic pressure
      2. Transudate leaks into peritoneum
4. Evaluation
   1. Diagnostic Paracentesis Indications
      1. Exclude extrahepatic causes of Ascites (see Ascites)
      2. Unexplained Ascites
      3. New onset Ascites
      4. Hospitalized patients
      5. Clinical deterioration
   2. Ascites characteristics
      1. Portal Hypertension (Cirrhosis)
         1. Serum Albumin - Ascites Albumin exceeds 1.1 mg/dl
      2. Ascites not due to Portal Hypertension
         1. Albumin gradient (see above) <1.1 mg/dl
         2. Consider other Ascites Causes
            1. Peritoneal carcinomatosis
            2. Abdominal Tuberculosis
5. Management: Medical Management
   1. See Spontaneous Bacterial Peritonitis
   2. Sodium restriction
      1. Maximum salt intake: 2 grams per day
      2. Salt restriction controls Ascites in 10-20% patients
   3. Diuretics
      1. Spironolactone (Aldactone) 25-50 mg tid-qid
         1. Effective in 40-75% of cases
      2. Furosemide (Lasix) 40 mg orally once to twice daily may be added
      3. Goal
         1. Urine Sodium exceeds Urine Potassium
         2. Do not allow Serum Creatinine to rise over 3.0
   4. Fluid Restriction
      1. Indicated for Serum Sodium <125 meq/L
   5. Avoid provocative agents
      1. Avoid NSAIDs (increase renal Sodium retention)
      2. Avoid Beta Blockers and ACE Inhibitors (increase Hypotension risk)
6. Management: Interventions
   1. Therapeutic Paracentesis Indications
      1. Required in up to 10% of cases
      2. Up to 4-6 liters may be safely removed per Paracentesis without albumin replacement
         1. Risk of Paracentesis-induced circulatory dysfunction (PICD) with large volume Paracentesis
         2. Replace albumin if >6 Liters are removed
      3. Indications
         1. Significant patient discomfort
         2. Respiratory compromise
         3. Large Umbilical Hernia
         4. Recurrent Bacterial peritonitis
   2. Refractory Ascites
      1. Mortality approaches 20% in 6 months
      2. Temporizing measures
         1. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
         2. Peritoneovenous Shunt
      3. Liver Transplantation
         1. See Cirrhosis
         2. Consider for all cirrhotic patients with Ascites
7. Prognosis
   1. Associated with increased mortality risk
   2. Poor prognostic sign for Cirrhosis course
8. Complications
   1. Spontaneous Bacterial Peritonitis
   2. Umbilical Hernia with risk of rupture
9. References
   1. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
   2. Garcia (2001) Postgrad Med 109(2):91-103 [PubMed]
   3. Zervos (2001) Am J Surg 181(3):256-64 [PubMed]