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