Management and complications

of Ascites

- Shravan ( R3 )
FACTS :

 60 % of cirrhotic pts will develop ASCITES , by

end of 10 yrs
 Portal hypertension > 12 mmHg
 Ideally Ascitic tapping should be done in all
patients suspected to have SBP
 Grading of ASCITES
GRADE SEVERITY CLINICAL USG TREATMENT

1 MILD -- + Sodium restriction

Sodium restriction
2 MODERATE + ++ Diuretics

Paracentesis
3 SEVERE ++ +++ Sodium restriction
Diuretics
 MINIMUM AMOUNT OF FLUID
REQUIRED
TEST MINIMUM FLUID IN (ml.)
Puddle Sign 120
Shifting Dullness 500
Fluid Thrill 1000- 1500
USG 100
CT Scan 50
 Treatment of Ascites
 Fluid restriction
 Salt restriction
( mild < 2 gm/day , moderate : < 1gm/day )
 Diuretics ( maintain ratio : 100 : 40 )

 Therapeutic Ascitic tapping ( LVP + albumin )

1) To start with aldosterone antagonist ( mono drug) , later can add furosemide ( 2 drug )

2) weight loss : 0.5 kg/day in patients without edema

1 kg/day in patients with edema

3) All diuretics should be discontinued if there is severe hyponatremia ( Na+ <120mmol/L),

progressive renal failure, worsening hepatic encephalopathy or incapacitating muscle
cramps .

4) Furosemide should be stopped if there is severe hypokalemia (<3 mmol/L).

Aldactone should be stopped if there is severe hyperkalemia ( >6 mmol/L).

5) LVP + Albumin ( 8gm/l of ascitic fluid removed)

 Complications
 Refractory ascites
 SBP ( spontaneous bacterial peritonitis )
 Hepatic encephalopathy - Grading
 HRS ( hepato renal syndrome ) - 2 types
 HPS ( hepato pulmonary syndrome ) - TRIAD
 Porto – Pulmonary HTN
 Hepatic hydrothorax
Refractory ascites
 First line Rx : LVP + Albumin ( 8gm/l )
 Second line Rx : TIPS
 Other shunts :
1) Peritoneo-venous ( le-veen , denver )
2)Porto – Systemic shunt
 LIVER TRANSPLANT
 TIPSS
 Merit : less recurrence
 De-merit : slow , needs diuretics ,
precipitates HE
 Contra indicated : Bil > 5 , INR >2 ,
Child Pugh > 11 , MELD > 23
sepsis , HE 2 , ARF ,
Studies on TIPS vs LVP
SBP ( spontaneous bacterial peritonitis )
 Neutrophil count > 250 (+/- positive culture )
 Bacter-ascites : Neutrophic < 250 , culture +
 If fever ---> treat as SBP
 If no fever --> repeat paracentensis ---> SBP +/-
 NEED TO R/O SECONDARY BACTERIAL
PERITONITIS
 Treatment of SBP
 First choice : 3rd gen cephalosporins
 Second choice : augmentin , Fqs
 Treatment response : repeat tapping > 48 hrs
 Give ALBUMIN ( 1st : 1.5 gm/kg -> 2nd : 1
gm/kg)
 CLINICAL TRIALS
 Prophylaxis for SBP
 Secondary : Norflox 400mg od daily /
 Ciproflox 750mg weekly once
 Bactrim DS od daily
 Primary : severe dis : ceftriaxone
 non severe dis : FQ, Bactrim DS
 HRS ( hepato renal syndrome )


 TYPES OF HRS
HRS COURSE CREAT TRIGGERED Others
TYPE 1 RAPID  >2.5mg/dl , SEPSIS ( SBP)
( dangerous ) < 2 weeks  GFR < 20 UGI Bleed
ml/min Acute hepatitis
Over diuresis
LVP
Cholestasis
TYPE 2 SLOW  > 1.5mg/dl -- Diuretic
( benign ) upto 6 months  GFR <40 resistance
ml/min and
Refractory
ascites
 Pathophysiology
 Splanchnic vasodilataion
 RAS – increased activity
 Sympathetic activity
 Cirrhotic cardiomyopathy
 Vasomediators – NO , TxA2 , Endothelin1, LK
 Treatment of HRS
 First choice : Terlipressin ( 1mg/ 4-6 hrly) +
albumin

 Nor epinephrine + albumin

 Midodrine + octreotide + albumin
 TIPSS
 Renal transplant
PROPHYLAXIS FOR HRS :
• All SBP pts should recieve albumin

• Severe alcoholic hepatitis pts to be given

pentoxyphylline

• Antibiotics – Norfloxacin
 Differential diagnosis :
PRE RENAL ATN HRS CKD

Urine Na+ <10 >20 <10 >30

Proteinuria nil < 500 < 500 >500

Ur cr/ plasma cr >20 <15 >30 < 20

Precipitants Decreased Decreased CLD, SBP , Renal disease

effective arterial effective arterial UGI bleed ,
Volume Volume Refractory
ascites
Volume Immediately Maintain NOT IMPROVED Maintain
expansion improved euvolemic status euvolemic status
• References :
1) EASL guidelines
2) Up to date
3) Harrison