Korean J Gastroenterol.  2018 Aug;72(2):49-55. 10.4166/kjg.2018.72.2.49.

Ascites

• Jeong SW

• KMID: 2418763
• DOI: http://doi.org/10.4166/kjg.2018.72.2.49

Abstract

Ascites is the most common cause of decompensation in cirrhosis, and 5% to 10% of patients with compensated cirrhosis develop ascites each year. The main factor of ascites formation is renal sodium retention due to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system by the reduced effective volume secondary to splanchnic arterial vasodilation. Diagnostic paracentesis is indicated in all patients with a new onset of grade 2 or 3 ascites and in those admitted to hospital for any complication of cirrhosis. A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension with an accuracy of approximately 97%. Sodium restriction, diuretics, and large volume paracentesis are the mainstay of treatment in grade 1 to 3 ascites. The refractoriness of ascites is associated with a poor prognosis with a median survival of approximately six months. Repeated large volume paracentesis plus albumin is the first line treatment, and liver transplantation is recommended in patients with refractory ascites. A careful selection of patients is also important to obtain the beneficial effects of transjugular intrahepatic portosystemic shunts in refractory ascites. This review details the recent diagnosis and treatment of cirrhotic ascites.

Keyword

Ascites; Liver cirrhosis; Hypertension portal

MeSH Terms

Ascites*
Diagnosis
Diuretics
Fibrosis
Humans
Hypertension, Portal
Liver Cirrhosis
Liver Transplantation
Paracentesis
Portasystemic Shunt, Surgical
Prognosis
Renin-Angiotensin System
Sodium
Sympathetic Nervous System
Vasodilation
Diuretics
Sodium

Reference

References

1. Ginés P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987; 7:122–128.

2. D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006; 44:217–231.

3. Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodés J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988; 8:1151–1157.

4. Runyon BA. Care of patients with ascites. N Engl J Med. 1994; 330:337–342.

5. Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis. 2001; 33:41–48.

6. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992; 117:215–220.

7. European Association for the Study of the Liver. Electronic address: [e-mail]; European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69:406–460.

8. Korean Association for the Study of the Liver (KASL). 2017 clinical practice guidelines for liver cirrhosis: ascites and related complications. Clin Mol Hepatol. 2018 Jul 9. [Epub ahead of print].

9. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990; 98:127–133.

10. Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB. Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. J Hepatol. 2001; 34:215–221.

11. Woo JJ, Koh YY, Kim HJ, Chung JW, Chang KS, Hong SP. N-terminal pro B-type natriuretic peptide and the evaluation of cardiac dysfunction and severity of disease in cirrhotic patients. Yonsei Med J. 2008; 49:625–631.

12. Trautwein C, Friedman SL, Schuppan D, Pinzani M. Hepatic fibrosis: concept to treatment. J Hepatol. 2015; 62:S15–S24.

13. Bernardi M, Laffi G, Salvagnini M, et al. Efficacy and safety of the stepped care medical treatment of ascites in liver cirrhosis: a randomized controlled clinical trial comparing two diets with different sodium content. Liver. 1993; 13:156–162.

14. Reynolds TB, Lieberman FL, Goodman AR. Advantages of treatment of ascites without sodium restriction and without complete removal of excess fluid. Gut. 1978; 19:549–553.

15. Morando F, Rosi S, Gola E, et al. Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: a re-al-life cross-sectional study. Liver Int. 2015; 35:1508–1515.

16. Pockros PJ, Reynolds TB. Rapid diuresis in patients with ascites from chronic liver disease: the importance of peripheral edema. Gastroenterology. 1986; 90:1827–1833.

17. Bernardi M, Trevisani F, Gasbarrini A, Gasbarrini G. Hepatorenal disorders: role of the renin-angiotensin-aldosterone system. Semin Liver Dis. 1994; 14:23–34.

18. Bernardi M, Servadei D, Trevisani F, Rusticali AG, Gasbarrini G. Importance of plasma aldosterone concentration on the natriuretic effect of spironolactone in patients with liver cirrhosis and ascites. Digestion. 1985; 31:189–193.

19. Angeli P, Dalla Pria M, De Bei E, et al. Randomized clinical study of the efficacy of amiloride and potassium canrenoate in non-azotemic cirrhotic patients with ascites. Hepatology. 1994; 19:72–79.

20. Angeli P, Fasolato S, Mazza E, et al. Combined versus sequential diuretic treatment of ascites in non-azotaemic patients with cirrhosis: results of an open randomised clinical trial. Gut. 2010; 59:98–104.

21. Santos J, Planas R, Pardo A, et al. Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety. J Hepatol. 2003; 39:187–192.

22. Perez-Ayuso RM, Arroyo V, Planas R, et al. Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites. Relationship between the diuretic response and the activity of the renin-aldosterone system. Gastroenterology. 1983; 84(5 Pt 1):961–968.

23. Elfert AA, Abo Ali L, Soliman S, et al. Randomized placebo-controlled study of baclofen in the treatment of muscle cramps in patients with liver cirrhosis. Eur J Gastroenterol Hepatol. 2016; 28:1280–1284.

24. Ginès P, Titó L, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology. 1988; 94:1493–1502.

25. Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a metaanalysis of randomized trials. Hepatology. 2012; 55:1172–1181.

26. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010; 53:397–417.

27. Moreau R, Valla DC, Durand-Zaleski I, et al. Comparison of outcome in patients with cirrhosis and ascites following treatment with albumin or a synthetic colloid: a randomised controlled pilot trail. Liver Int. 2006; 26:46–54.

28. Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996; 23:164–176.

29. Moore KP, Wong F, Gines P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 2003; 38:258–266.

30. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology. 1988; 95:1351–1355.

31. Choi CH, Ahn SH, Kim DY, et al. Long‐ term clinical outcome of large volume paracentesis with intravenous albumin in patients with spontaneous bacterial peritonitis: a randomized prospective study. J Gastroenterol Hepatol. 2005; 20:1215–1222.

32. Huonker M, Schumacher YO, Ochs A, Sorichter S, Keul J, Rössle M. Cardiac function and haemodynamics in alcoholic cirrhosis and effects of the transjugular intrahepatic portosystemic stent shunt. Gut. 1999; 44:743–748.

33. Sanyal AJ, Freedman AM, Luketic VA, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology. 1997; 112:889–898.

34. Wong F, Sniderman K, Liu P, Blendis L. The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt. Gastroenterology. 1997; 112:899–907.

35. Gerbes AL, Gülberg V, Waggershauser T, Holl J, Reiser M. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis: comparison of patients with ascites, with refractory ascites, or without ascites. Hepatology. 1998; 28:683–688.

36. Casado M, Bosch J, García-Pagán JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology. 1998; 114:1296–1303.

37. Riggio O, Angeloni S, Salvatori FM, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoro-ethylene-covered stent grafts. Am J Gastroenterol. 2008; 103:2738–2746.

38. Sauerbruch T, Mengel M, Dollinger M, et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology. 2015; 149:660–668.e1.

39. Wang Q, Lv Y, Bai M, et al. Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding. J Hepatol. 2017; 67:508–516.

40. Lebrec D, Giuily N, Hadengue A, et al. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. French Group of Clinicians and a Group of Biologists. J Hepatol. 1996; 25:135–144.

41. Salerno F, Borroni G, Moser P, et al. Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients. Am J Gastroenterol. 1993; 88:514–519.

42. Guardiola J, Baliellas C, Xiol X, et al. External validation of a prognostic model for predicting survival of cirrhotic patients with refractory ascites. Am J Gastroenterol. 2002; 97:2374–2378.

43. Durand F, Valla D. Assessment of prognosis of cirrhosis. Semin Liver Dis. 2008; 28:110–122.

44. Luca A, Angermayr B, Bertolini G, et al. An integrated MELD model including serum sodium and age improves the prediction of early mortality in patients with cirrhosis. Liver Transpl. 2007; 13:1174–1180.

45. Solà E, Sanchez-Cabús S, Rodriguez E, et al. Effects of alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites. Liver Transpl. 2017; 23:583–593.

46. Caldwell J, Edriss H, Nugent K. Chronic peritoneal indwelling catheters for the management of malignant and nonmalignant ascites. Proc (Bayl Univ Med Cent). 2018; 31:297–302.

47. Zaak D, Paquet KJ, Kuhn R. Prospective study comparing human albumin vs. reinfusion of ultrafiltrate-ascitic fluid after total paracentesis in cirrhotic patients with tense ascites. Z Gastroenterol. 2001; 39:5–10.

48. Graziotto A, Rossaro L, Inturri P, Salvagnini M. Reinfusion of Concentrated Ascitic Fluid versus Total Paracentesis. A randomized prospective trial. Dig Dis Sci. 1997; 42:1708–1714.

49. Elia C, Graupera I, Barreto R, et al. Severe acute kidney injury associated with non-steroidal anti-inflammatory drugs in cirrhosis: a case-control study. J Hepatol. 2015; 63:593–600.

50. Claria J, Kent JD, López-Parra M, et al. Effects of celecoxib and naproxen on renal function in nonazotemic patients with cirrhosis and ascites. Hepatology. 2005; 41:579–587.

51. Hayes PC, Davis JM, Lewis JA, Bouchier IA. Meta-analysis of value of propranolol in prevention of variceal haemorrhage. Lancet. 1990; 336:153–156.

52. Serste T, Francoz C, Durand F, et al. Beta-blockers cause paracentesis-induced circulatory dysfunction in patients with cirrhosis and refractory ascites: a crossover study. J Hepatol. 2011; 55:794–799.

53. Kurt M. Deleterious effects of beta‐ blockers on survival in patients with cirrhosis and refractory ascites. Hepatology. 2011; 53:1411–1412.