Description
The management of ascites in chronic liver disease involves a multifaceted approach addressing the underlying liver dysfunction, fluid retention, and associated complications.
Sodium restriction is a fundamental dietary intervention to manage ascites, aiming to decrease fluid accumulation by limiting water retention. Diuretics, such as spironolactone and furosemide, are commonly prescribed to promote diuresis and reduce ascitic fluid buildup by increasing urine output. Regular monitoring of weight, blood pressure, and renal function is essential to adjust diuretic dosages and prevent electrolyte imbalances. Paracentesis, a procedure involving the removal of excess ascitic fluid through a needle, may be performed for therapeutic and diagnostic purposes in cases of severe ascites. Transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiology procedure that can be considered in refractory cases to redirect blood flow and reduce portal hypertension. Antibiotic prophylaxis is often recommended to prevent spontaneous bacterial peritonitis (SBP), a serious complication associated with ascites. Liver transplantation is the ultimate therapeutic option for chronic liver disease with refractory ascites, offering a chance for long-term resolution.
Résumé
- Ascites, a hallmark of hepatic decompensation, affects 90% of cirrhotic patients and carries a poor prognosis with a 40% one-year mortality rate. It's characterized by fluid accumulation in the peritoneal cavity, often linked to portal hypertension, where the hepatic venous pressure gradient exceeds 6 mm of Hg. While ascites can result from tuberculosis, malignancy, or severe hypoalbuminemia, it signifies portal hypertension in chronic liver disease.
- Pathophysiologically, ascites in cirrhosis stems from low albumin levels, which reduce oncotic pressure, aldosterone metabolism impairment leading to salt and water retention, and decreased renal blood flow activating the renin-angiotensin system. Ascites is graded as mild (detectable only by ultrasound), moderate (evident through abdominal distension), and severe (marked abdominal distension with flank fullness), each presenting varying degrees of patient discomfort.
- Initial management involves salt restriction and diuretics, often Spironolactone and Furosemide. Close monitoring is crucial to assess weight loss (0.5-1 kg/day), adjust diuretic dosages to avoid complications like hyponatremia or hyperkalemia, and manage potential muscle cramps with magnesium supplementation. Refractory ascites is classified as diuretic-intolerant (complications at low doses) or diuretic-resistant (no response to maximum doses), necessitating compliance assessments and potentially Large Volume Paracentesis.
- Large Volume Paracentesis (LVP) is safe up to 5 liters, though some tap more, with albumin replacement crucial after removing over 5 liters to prevent post-paracentesis circulatory dysfunction. INR and platelet investigations aren't generally needed unless the patient is unstable. Hyponatremia is managed with water restriction, diuretics cessation, and sometimes Tolvaptan.
- Other treatments include TIPS (transjugular intrahepatic portosystemic shunting) for refractory variceal bleeding and ascites, though it's not suitable for all patients and is a bridge to liver transplant. Liver transplantation remains the definitive cure, especially for refractory ascites, SBP (spontaneous bacterial peritonitis), and HRS (hepatorenal syndrome), with patients considered for listing based on MELD score and ascites severity.
Exemple de certificat
À propos des intervenants
Dr Uday Sanglodkar
Senior Consultant of Hepatology and Liver Transplant Global Hospital, Mumbai
Divulgation financière
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