Ascites Cirr
Intro:
12th leading cause of death in US is cirrhosis
Ascites is the most common complication of cirrhosis (Encephalopathy and bleeding the other 2)
50% of compensated cirrhosis will develop ascites in 10 years
Once develop ascites, mortality 15% in 1 year, upto 50% (2-5 years), if SBP, upto 50% in 1 year
Child’s C Alcoholic Liver Disease, if patient stop drinking (75% 3 year survival), if don’t (0%)
Once ascites refractory to routine medical therapy, mortality is 21% in 6 months
Approximately 1.5L needed before flanks become dull with percussion. If no flank dullness, < 10% chance of ascites
Consider DD of Ascites:
Cirrhosis (85%)
Alcoholic Hepatitis
Heart Failure
Cancer
Pancreatitis
Nephrotic syndrome
TB
Acute Liver Failure
Budd Chiari syndrome
Myxoedema
Post op lymphatic leak
Risk of paracentesis:
Only 1% complication (usually hematoma) even when >70% have abnormal coagulopathy
Haemoperitoneum and bowel entry is <1 in 1000 procedures (<0.1%)
No concensus on correcting INR but if >2.5 may consider giving prophylactic FFP and tap without needing for repeat INR.
(Study of 1100 LVP, no bleeding even when platelet < 19k, INR 8.7 with no prophylaxis)
If clinical evidence of active bleeding, then prophylactic FFP may be useful.
Site is 3 cm cephalad and medial to ASIS
If tap is grossly hemorrhagic repeat quickly on the other side as this suggest existing haemoperitoneum and need to consider HCC rupture.
Ascitic Fluid Analysis
First Tap:
Cell count and differential
Albumin
Total Protein
Culture (Blood culture bottle)
Glucose
LDH
AFB D/S
AFB culture
Cytology
Repeated Tap:
Cell count and differential
Consider Culture and Albumin after clinical judgement
Note: CA 125 is elevated in ascites due to pressure on the mesothelial cells, so be careful when interpreting this result
Treatment:
Stop Alcohol
- Child’s C Alcoholic Liver Disease, if patient stop drinking (75% 3 year survival), if don’t (0%)
Na restriction (Daily 2g / 88mmol Na)
- Random U/Na itself is useful only if <0 or >100mmol/L
- Random ratio U/Na to U/K > 1 correlate 24 h U Na excretion > 78 is 90% accurate
- Goal is 24h U Na > 78mmol/day (10mmol non urinary excretion) if patient consumption <88
- 10-15% may have 24n U Na excretion <78, so can consider Na restriction alone without diuretics
HypoNa is common but most of them still >125mmol/L (Only 1.2% < 120 and 5.7% < 125).
- Cirrhotics usually become symptomatic only <110
- Conivaptan / Tolvaptan can be considered but caution is advised.
- Fluid restriction is usually the treatment of choice
Diuretics
- Ratio of Spironolactone 100mg to Frusemide 40mg (Maximum 400 / 160mg day)
- Start with spironolactone then add on frusemide
- Can be increased every 3-5 days
- Amiloride if painful gynaecomastia but less effective than spironolactone
Albumin
- Weekly 25g Albumin for a year then every 2 weeks but very expensive
Monitoring:
Weight loss target is 0.5kg daily if oedema has resolved. Otherwise 1kg.
Tense Ascites:
5L paracentesis is safe without needing post paracentesis colloid infusion (if renal fx is normal)
Larger volumes (>5L) will need 5-8g albumin for every litre ascites removed
Strict Na restriction
Diuretics
Refractory Ascites:
Unresponsive to 400mg spironolactone and 160mg frusemide or maximal tolerated diuretic dose
Ascites recurs rapidly after paracentesis
Rule out non compliance Na restriction and NSAIDs
Once ascites refractory to routine medical therapy, mortality is 21% in 6 months
Treatment:
- Regular LVP (6L should last 10 days and 10L should last 17 days if Na restriction compliant)
- Transplant
- TIPS
- Peritoneovenous shunt
- Experimental: weekly albumin (25-50g), Clonidine (0.075mg bd), S/C Octreotide
edited 19th July 2010