Management of adult patients with ascites caused by cirrhosis†

Abstract

Ascites is the most common of the major complications of cirrhosis. The development of ascites is an important landmark in the natural history of cirrhosis and has been proposed as an indication for liver transplantation. The initial evaluation of a patient with ascites should include a history, physical evaluation, and abdominal paracentesis with ascitic fluid analysis. Treatment should consist of abstinence from alcohol, sodium restricted diet, and diuretics. This regimen is effective in Ϸ90% of patients. The treatment options for the diuretic-resistant patients include serial therapeutic paracenteses, liver transplantation, and peritoneovenous shunting. (HEPATOLOGY 1998;27;264-272.) PREAMBLE These guidelines provide a data-supported approach to the care of patients with ascites. They are based on the following: 1) a formal review and analysis of the published world literature (1,045 papers) on ascites (Medline Search from 1966-1996, search terms included ascites, diet therapy, drug therapy, radiotherapy, surgery, and therapy); 2) the American College of Physician' s Manual for Assessing Health Practices and Designing Practice Guidelines 1 ; and 3) several published and draft guidelines, including the American Association for the Study of Liver Diseases' Policy Statement on Development and Use of Practice Guidelines and American Gastroenterological Association' s Policy Statement on Guidelines 2 ; and 4) 15 years of experience on the part of the author in the clinical and laboratory investigations of and care for patients with this problem.These guidelines, intended for use by physicians, suggest preferable approaches to the diagnostic, therapeutic, and preventative aspects of care. These guidelines are intended to be flexible, in contrast with ''standards of care,'' which are inflexible policies to be followed in almost every case. 1 Furthermore, these guidelines were developed for the care of adult patients with clinically detectable ascites. Although the general approach may be applicable to children, the pediatric data base is much smaller and there may be unanticipated differences between adults and children. Patients with ascites that is detected by imaging modalities alone, but not yet clinically evident, are not included because of the lack of published information regarding the natural history of this entity.Specific recommendations are based on relevant published information. In an attempt to standardize recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases modified the categories of the Infectious Diseases Society of America' s Quality Standards. 3 These categories are reported with each recommendation, using the letters A through E to determine the strength of recommendation and roman numerals I through III to determine quality of evidence upon which recommendations are based, as follows: A, survival benefit; B, improved diagnosis; C, improvement in quality of life; D, relevant pathophysiologic parameters improved; E, impacts cost of heal...

The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club

“…The use of albumin has been contested by the Practice Guidelines Committee of the American Association for the Study of Liver Diseases. 34 There have been 5 randomized controlled trials comparing volume expansion with albumin with other forms of plasma expanders, including dextrans, collagen-based colloids, and hydroxyethyl starch. [35][36][37][38][39] All studies have shown that synthetic plasma expanders are as effective as albumin at preventing the clinical complications of paracentesis, namely hyponatremia or renal impairment.…”

Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis

“…In addition, the many dietary restrictions used to control symptoms and specifi c complications, such as ascites and hepatic encephalopathy, aggravate the nutritional status, predisposing the patients to infections and worsening of the functional hepatic status (21,34,37) .…”

Routine analysis of cirrhotic ascites for evidence of infection – not worth the effort?

“…The AASLD thus recommends testing of ascitic fluid for cell count and differential count, but not necessarily culture, for patients undergoing serial outpatient therapeutic paracentesis, each time the fluid is removed [4]. Given the low prevalence of SBP in asymptomatic patients, the question is whether we need to undertake ascitic fluid cell count routinely in all cases of paracentesis.…”