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Cirrhotic ascites

ascitesAscites is an accumulation of fluid in the abdomen that occurs as a complication of liver cirrhosis during evolution. The occurrence of ascites is due to decreased hepatic production of proteins (hypoalbuminemia), increased pressure in the portal system (portal hypertension) and lymphatic stasis.

Even if a patient does not have ascites, but has cirrhosis, it is recommended to periodically weighing. A sudden increase in weight or volume distension of the abdomen may suggest an accumulation of ascites fluid.

The diagnosis in ascites is on clinical criteria and laboratory investigations. Ascites causes a voluminous abdomen with prominent umbilicus, on the skin surface can be observed the development of collateral circulation (dilated vessels are visualized through the skin). As clinical maneuver it is performed the wave sign,  which becomes  positive when moving forward after tapping from side to side of the abdomen (due to transmission through fluid movement).

ascites ultrasoundUltrasound is the first investigation to confirm the diagnosis. It allows assessing the relative volume of ascites fluid. Through the paracentesis it is extracted ascites fluid through the abdominal wall, in order to evaluate the content of the liquid. Exploratory paracentesis can confirm whether the fluid is exudate (has more than 3g protein and occurs in old ascites) or transudate (less than 3 grams of proteins). It can also establish whether there are red cells in ascites fluid, or if there are bacteria’s, which would suggest a spontaneous bacterial peritonitis (severe infectious complication of ascites).

Treatment of ascites

Treatment of ascites is initiated with prolonged bed rest measures and imposes a regime without salt (you pay attention to foods that contain the hidden salt: vegetable, meat, mineral water, bread).

Medications which are administered in ascites are diuretics (they increase the fluid retention by the kidneys). Among them the most used is spironolactone, diuretic which spares the potassium and the furosemide which is usually associated with spironolactone.

  • Spironolactone is administered daily in doses between 50 and 400 mg, with an effect that is installed 2 = 3 days after the initial dose. Do not administer in cases where there is hyperkalemia or renal failure. As a side effect may appear gynecomastia (breast growth in men).

  • Furosemide is a diuretic very powerful and fast that associates with the diuretics that spare potassium. It is administered daily in doses between 40 and 160 mg.

In diuretic therapy it is monitored the daily diuresis (it is recommended that the patient should urinate at least 1500 ml), the patient’s weight and level of blood sodium and potassium it is monitored in the blood once every two days during the hospital stay.

Diuretic dose is determined by the doctor and it is adjusted depending on the diuresis, body weight and on the electrolyte values in blood products.

paracentesisParacentesis is a therapeutic method of removing ascites fluid, which is used in case of a large ascites or ascites that does not respond to treatment with diuretics (to remove less than 1 liter of urine per day despite treatment with diuretics). Paracentesis allows removal of 5 liters of fluid every two days. To eliminate the risk of a sharp drop in blood pressure and eventual renal ischemia, is given albumin in plasma or in solution (8 grams per liter of ascites fluid is evacuated).

To refractory ascites an alternative for paracentesis is the evacuation shunt. LeVeen peritoneovenous shunts are less used, TIPS (Transjugular portosystemic intrahepatic shunts) consists of a modern interventional technique for solving an ascites or pleural unresponsive to other treatment.

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