Treatment of ascites
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Ascites is the most common complication of cirrhosis and occurs in more than half of all patients with cirrhosis. The development of ascites indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate. Conventional therapies used for the treatment of ascites include sodium restriction (<88 mmol/d), diuretics, and large volume paracentesis (LVP) (>5 L). The most effective diuretic combination is that of a potassium-sparing, distal-acting diuretic (eg, spironolactone) with a loop diuretic (eg, furosemide). LVP provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients. Post-paracentesis circulatory dysfunction (PPCD) may occur after LVP and is characterized by hyponatremia, azotemia, and an increase in plasma renin activity. PPCD is associated with an increased mortality and may be prevented by administration of albumin intravenously (6 to 8 g/L of ascites removed) along with LVP. The development of either diuretic-resistant or diuretic-intractable ascites occurs in approximately 5% to 10 % of all cases of ascites. This is a poor prognostic sign, as 50% of such patients die within 6 months of its development. The only definitive therapy for refractory ascites with cirrhosis is orthotopic liver transplantation. The other options that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portosystemic shunts (TIPS). The TIPS procedure has not been shown to have any influence on survival in patients with cirrhosis and refractory ascites, and TIPS is contraindicated in patients who have advanced liver failure because it can hasten death in such individuals. Peritoneovenous shunts are associated with a high incidence of complications and frequent occlusion. They are, therefore, rarely used for refractory ascites. Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites. It may precipitate hepatorenal syndrome. The overall mortality rate from an episode of SBP is approximately 20%. Following an episode of SBP, the 1-year mortality rate approaches 70%. Hospitalized patients should be treated with intravenous third-generation cephalosporins (eg, cefotaxime), and patients at risk should receive prophylaxis with either orally administered quinolones (eg, norfloxacin) or cotrimoxazole.
- Runyon BA: Ascites. In Diseases of the Liver. Edited by Schiff L, Schiff ER. Philadephia: Lippincott; 1993:990–1015.
- Runyon BA: Care of patients with ascites. N Engl J Med 1994, 330:337–342. CrossRef
- Gines P, Quintero E, Arroyo V, et al.: Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987, 7:122–128. CrossRef
- Schrier RW, Arroyo V, Bernardi M, et al.: Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988, 8:1151–1157. CrossRef
- Cardenas A, Bataller R, Arroyo V: Mechanisms of ascites formation. Clin Liver Dis 2000, 4:447–465. CrossRef
- Gines P, Schrier RW: The arterial vasodilation hypothesis of ascites formation in cirrhosis. In Ascites and Renal Dysfunction in Liver Disease. Edited by Arroyo V, Gines P, Rodes J, Schrier RW. Malden, MA: Blackwell Science; 1999:411–427.
- Martin PY, Gines P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998, 339:533–541. CrossRef
- Reynolds TB, Geller HM, Kuzma OT, Redeker AG: Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med 1960, 263:734–739. CrossRef
- Runyon BA: Management of adult patients with ascites caused by cirrhosis. Hepatology 1998, 27:264–272. CrossRef
- Fogel MR, Sawhney VK, Neal EA, et al.: Diuresis in the ascitic patient: a randomized controlled trial of three regimens. J Clin Gastroenterol 1981, (3 suppl 1):73–80. CrossRef
- Sungaila I, Bartle WR, Walker SE, et al.: Spironolactone pharmacokinetics and pharmacodynamics in patients with cirrhotic ascites. Gastroenterology 1992, 102:1680–1685.
- Gines P, Arrovo V, Rodes J: Pharmacotherapy of ascites associated with cirrhosis. Drugs 1992, 43:316–332.
- Angeli P, Dalla PM, De Bei E, et al.: Randomized clinical study of the efficacy of amiloride and potassium canrenoate in nonazotemic cirrhotic patients with ascites. Hepatology 1994, 19:72–79. CrossRef
- Li CP, Lee FY, Hwang SJ, et al.: Treatment of mastalgia with tamoxifen in male patients with liver cirrhosis: a randomized crossover study. Am J Gastroenterol 2000, 95:1051–1055. CrossRef
- Stanley MM, Ochi S, Lee KK, et al.: Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites. N Engl J Med 1989, 321:1632–1638. CrossRef
- Gines P, Tito L, Arroyo V, et al.: Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988, 94:1493–1502.
- Gines A, Fernandez-Esparrach G, Monescillo A, et al.: Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996, 111:1002–1010. CrossRef
- McVay PA, Toy PT: Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991, 31:164–171. CrossRef
- Rossle M, Ochs A, Gulberg V, et al.: A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000, 342:1701–1707. Important study. CrossRef
- 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. CrossRef
- Gines P, Uriz J, Calahorra B, et al.: TIPS versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002, 123:1839–1847. Important study. CrossRef
- Sanyal AJ, Genning C, Reddy KR, et al.: The North American study for the treatment of refractory ascites. Gastroenterology 2003, 124:634–641. Important study. CrossRef
- Malinchoc M, Kamath PS, Gordon FD, et al.: A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000, 31:864–871. CrossRef
- Gines P, Arroyo V, Vargas V, et al.: Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991, 325:829–835. CrossRef
- Runyon BA, Akriviadis EA, Sattler FR, Cohen J: Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci 1991, 36:1782–1786. CrossRef
- Castellote J, Lopez C, Gornals J, et al.: Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips. Hepatology 2003, 37:893–896. CrossRef
- Such J, Runyon BA: Spontaneous bacterial peritonitis. Clin Infect Dis 1998, 27:669–674.
- Garcia N Jr, Sanyal AJ: Minimizing ascites. Complication of cirrhosis signals clinical deterioration. Postgrad Med 2001, 109:91–103.
- Navasa M, Follo A, Llovet JM, et al.: Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996, 111:1011–1017. CrossRef
- Ricart E, Soriano G, Novella MT, et al.: Amoxicillinclavulanic acid versus cefotaxime in the therapy of bacterial infections in cirrhotic patients. J Hepatol 2000, 32:596–602. CrossRef
- Fong TL, Akriviadis EA, Runyon BA, Reynolds TB: Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis. Hepatology 1989, 9:423–426. CrossRef
- Runyon BA, McHutchison JG, Antillon MR, et al.: Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology 1991, 100:1737–1742.
- Follo A, Llovet JM, Navasa M, et al.: Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994, 20:1495–1501. CrossRef
- Sort P, Navasa M, Arroyo V, et al.: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999, 341:403–409. CrossRef
- Bass NM: Intravenous albumin for spontaneous bacterial peritonitis in patients with cirrhosis. N Engl J Med 1999, 341:443–444. CrossRef
- Brand RE: Intravenous albumin in patients with cirrhosis and spontaneous bacterial peritonitis: is it worth the cost? Am J Gastroenterol 1999, 94:3404–0. CrossRef
- Rolachon A, Cordier L, Bacq Y, et al.: Ciprofloxacin and long-term prevention of spontaneous bacterial peritonitis: results of a prospective controlled trial. Hepatology 1995, 22(4 Pt 1):1171–1174.
- Singh N, Gayowski T, Yu VL, Wagener MM: Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med 1995, 122:595–598.
- Gines P, Rimola A, Planas R, et al.: Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology 1990, 12(4 Pt 1):716–724. CrossRef
- Bernard B, Grange JD, Khac EN, et al.: Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999, 29:1655–1661. CrossRef
- Llach J, Rimola A, Navasa M, et al.: Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites: relevance of ascitic fluid protein concentration. Hepatology 1992, 16:724–727. CrossRef
- Garcia-Tsao G: Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 2001, 120:726–748. CrossRef
- Grange JD, Roulot D, Pelletier G, et al.: Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial. J Hepatol 1998, 29:430–436. CrossRef
- Chang CS, Yang SS, Kao CH, et al.: Small intestinal bacterial overgrowth versus antimicrobial capacity in patients with spontaneous bacterial peritonitis. Scand J Gastroenterol 2001, 36:92–96.
- Sandhu BJ, Jain R, Singh J, et al.: bination of norfloxacin and cisapride in prevention of SBP in high risk patients: a new approach [abstract] Gastroenterology 2001, 120 (supp 1):A-376.
- Unbiased Prescription Drug Comparison Shopper. June 26, 2001.
- Gines P, Arroyo V: Is there still a need for albumin infusions to treat patients with liver disease? Gut 2000, 46:588–590. CrossRef
- Milliner DS, Shinaberger JH, Shuman P, Coburn JW: Inadvertent aluminum administration during plasma exchange due to aluminum contamination of albumin-replacement solutions. N Engl J Med 1985, 312:165–167. CrossRef
- Wills MR, Savory J: Aluminium poisoning: dialysis encephalopathy, osteomalacia, and anaemia. Lancet 1983, 2:29–34. CrossRef
- Ring J, Seifert J, Lob G, et al.: Human serum albumin incompatibility: clinical and immunological investigations. Klin Wochenschr 1974, 52:595–598. CrossRef
- Tito L, Gines P, Arroyo V, et al.: Total paracentesis associated with intravenous albumin management of patients with cirrhosis and ascites. Gastroenterology 1990, 98:146–151.
- Sanyal AJ, Freedman AM, Purdum PP, et al.: The hematologic consequences of transjugular intrahepatic portosystemic shunts. Hepatology 1996, 23:32–39. CrossRef
- Sanyal AJ, Reddy KR: Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998, 115:110–115. CrossRef
- Lake JR: The role of transjugular shunting in patients with ascites. N Engl J Med 2000, 342:1745–1747. CrossRef
- Campbell PJ, Greig PD, Blendis LM: The LeVeen shunt: mechanisms of action, indications and contraindications to its use. Dig Dis 1986, 4:178–192.
- Soriano G, Guarner C, Tomas A, et al.: Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. Gastroenterology 1992, 103:1267–1272.
- Inadomi J, Sonnenberg A: Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis. Gastroenterology 1997, 113:1289–1294. CrossRef
- 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. CrossRef
- Treatment of ascites
Current Treatment Options in Gastroenterology
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