Ascites medical therapy: Difference between revisions
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{{Ascites}} | {{Ascites}} | ||
{{CMG}} {{AE}} {{ | {{CMG}} {{AE}} {{EG}} | ||
==Overview== | ==Overview== | ||
The mainstays of first-line treatment of patients with [[cirrhosis]] and ascites include (1) education regarding dietary [[sodium]] restriction (2000 mg per day [88 mmol per day]) and (2) oral [[diuretics]]. Medical therapy is based on different grades of ascites. Medical therapy would inhibit different processes in [[pathophysiology]] of ascites. First-line treatment of patients with [[cirrhosis]] and ascites consists of [[sodium]] restriction (88 mmol per day [2000 mg per day], [[diet]] education), and [[diuretics]] (oral [[spironolactone]] with or without oral [[furosemide]]). | |||
==Ascites Treatment Recommendations (DO NOT EDIT)== | |||
==Ascites | ===Recommendations for the treatment of Ascites<ref name=":0">{{Cite web|url=https://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf|title=Management of adult patients with ascites due to cirrhosis: update 2012|last=Runyon|first=BA|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>=== | ||
* Patients with ascites who are thought to have an [[alcohol]] component to their [[liver]] injury should abstain from [[alcohol]] consumption. | |||
* [[Baclofen]] can be given to reduce [[alcohol]] craving and [[alcohol]] consumption in patients with ascites in the setting of [[alcoholic liver disease]]. | |||
* First-line treatment of patients with [[cirrhosis]] and ascites consists of [[sodium]] restriction (88 mmol per day [2000 mg per day], [[diet]] education), and [[diuretics]] (oral [[spironolactone]] with or without oral [[furosemide]]). | |||
* Fluid restriction is not necessary unless serum [[sodium]] is less than 125 mmol/L. | |||
* Vaptans may improve serum [[sodium]] in patients with [[cirrhosis]] and ascites. However their use does not currently appear justified in view of their expense, potential risks, and lack of evidence of efficacy in clinically meaningful outcomes. | |||
* An initial therapeutic [[Abdomen|abdominal]] [[paracentesis]] should be performed in patients with tense ascites. [[Sodium]] restriction and oral [[diuretics]] should then be initiated. | |||
* Diuretic-sensitive patients should preferably be treated with [[sodium]] restriction and oral [[Diuretic|diuretics]] rather than with serial [[Paracentesis|paracenteses]]. | |||
* Use of [[angiotensin converting enzyme inhibitors]] and [[angiotensin receptor blockers]] in patients with [[cirrhosis]] and ascites may be harmful, must be carefully considered in each patient, monitoring [[blood pressure]] and [[renal function]]. | |||
* The use of [[nonsteroidal anti-inflammatory drugs]] should be avoided in patients with [[cirrhosis]] and ascites, except in special circumstances. | |||
* [[Liver transplantation]] should be considered in patients with [[cirrhosis]] and ascites. | |||
===Recommendations for the treatment of Ascites=== | ===Recommendations for the treatment of Refractory Ascites<ref name=":0" />=== | ||
* The risks versus benefits of [[beta blockers]] must be carefully weighed in each patient with refractory ascites. Systemic [[hypotension]] often complicates their use. Consideration should be given to discontinuing or not initiating these [[drugs]] in this setting. | |||
* The use of [[angiotensin converting enzyme inhibitors]] and [[angiotensin receptor blockers]] should be avoided in patients [[refractory]] ascites. Systemic [[hypotension]] often complicates their use. | |||
* Oral [[midodrine]] has been shown to improve clinical outcomes and survival in patients with [[refractory]] ascites; its use should be considered in this setting. | |||
* Serial therapeutic [[Paracentesis|paracenteses]] are a treatment option for patients with [[refractory]] ascite. | |||
* Post-[[paracentesis]] [[albumin]] infusion may not be necessary for a single [[paracentesis]] of less than 4 to 5 L. | |||
* For large-volume [[Paracentesis|paracenteses]], an [[albumin]] infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended. | |||
* Referral for [[liver transplantation]] should be expedited in patients with [[refractory]] ascites, if the patient is otherwise a candidate for [[transplantation]]. | |||
* [[Transjugular intrahepatic portosystemic shunt|TIPS]] may be considered in appropriately selected patients who meet [[criteria]] similar to those of published randomized trials. | |||
* [[Peritoneovenous shunt]], performed by a [[surgeon]] or inteventional [[Radiologists|radiologist]] experienced with this technique, should be considered for patients with [[refractory]] ascites who are not candidates for [[Paracentesis|paracenteses]], [[transplant]], or [[TIPS]]. | |||
==Medical Therapy== | ==Medical Therapy== | ||
* The mainstays of first-line treatment of patients with [[cirrhosis]] and ascites include:<ref name=":0" /> | |||
** Education regarding dietary [[sodium]] restriction (2000 mg per day [88 mmol per day]) | |||
** Oral [[diuretics]] | |||
* Medical therapy is based on different grades of ascites.<ref name="pmid20633946">{{cite journal |vauthors= |title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis |journal=J. Hepatol. |volume=53 |issue=3 |pages=397–417 |year=2010 |pmid=20633946 |doi=10.1016/j.jhep.2010.05.004 |url=}}</ref> | * Medical therapy is based on different grades of ascites.<ref name="pmid20633946">{{cite journal |vauthors= |title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis |journal=J. Hepatol. |volume=53 |issue=3 |pages=397–417 |year=2010 |pmid=20633946 |doi=10.1016/j.jhep.2010.05.004 |url=}}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
| Line 92: | Line 100: | ||
* '''3 Grade III''' | * '''3 Grade III''' | ||
** [[Paracentesis]] followed by [[salt]] restriction and [[diuretics]] | ** [[Paracentesis]] followed by [[salt]] restriction and [[diuretics]] | ||
* '''4 Refractory''' | |||
** 4.1 '''Adult''' | |||
*** Preferred regimen (1): [[Midodrine]] 7.5 mg [[Per os|PO]] q8h | |||
==References== | ==References== | ||
Revision as of 17:38, 18 January 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]
Overview
The mainstays of first-line treatment of patients with cirrhosis and ascites include (1) education regarding dietary sodium restriction (2000 mg per day [88 mmol per day]) and (2) oral diuretics. Medical therapy is based on different grades of ascites. Medical therapy would inhibit different processes in pathophysiology of ascites. First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education), and diuretics (oral spironolactone with or without oral furosemide).
Ascites Treatment Recommendations (DO NOT EDIT)
Recommendations for the treatment of Ascites[1]
- Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption.
- Baclofen can be given to reduce alcohol craving and alcohol consumption in patients with ascites in the setting of alcoholic liver disease.
- First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day], diet education), and diuretics (oral spironolactone with or without oral furosemide).
- Fluid restriction is not necessary unless serum sodium is less than 125 mmol/L.
- Vaptans may improve serum sodium in patients with cirrhosis and ascites. However their use does not currently appear justified in view of their expense, potential risks, and lack of evidence of efficacy in clinically meaningful outcomes.
- An initial therapeutic abdominal paracentesis should be performed in patients with tense ascites. Sodium restriction and oral diuretics should then be initiated.
- Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses.
- Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in patients with cirrhosis and ascites may be harmful, must be carefully considered in each patient, monitoring blood pressure and renal function.
- The use of nonsteroidal anti-inflammatory drugs should be avoided in patients with cirrhosis and ascites, except in special circumstances.
- Liver transplantation should be considered in patients with cirrhosis and ascites.
Recommendations for the treatment of Refractory Ascites[1]
- The risks versus benefits of beta blockers must be carefully weighed in each patient with refractory ascites. Systemic hypotension often complicates their use. Consideration should be given to discontinuing or not initiating these drugs in this setting.
- The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided in patients refractory ascites. Systemic hypotension often complicates their use.
- Oral midodrine has been shown to improve clinical outcomes and survival in patients with refractory ascites; its use should be considered in this setting.
- Serial therapeutic paracenteses are a treatment option for patients with refractory ascite.
- Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L.
- For large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended.
- Referral for liver transplantation should be expedited in patients with refractory ascites, if the patient is otherwise a candidate for transplantation.
- TIPS may be considered in appropriately selected patients who meet criteria similar to those of published randomized trials.
- Peritoneovenous shunt, performed by a surgeon or inteventional radiologist experienced with this technique, should be considered for patients with refractory ascites who are not candidates for paracenteses, transplant, or TIPS.
Medical Therapy
- The mainstays of first-line treatment of patients with cirrhosis and ascites include:[1]
- Medical therapy is based on different grades of ascites.[2]
| Grade | Description | Therapy |
|---|---|---|
| Grade I | Mild fluid accumulation, only detectable with ultrasonography | No treatment |
| Grade II | Moderate fluid accumulation, detectable by physical examination | Sodium intake restriction and diuretics |
| Grade III | Severe fluid accumulation, detectable by inspection of flanks bulging | Large volume paracentesis followed by sodium intake restriction and diuretics |
- Medical therapy would inhibit different processes in pathophysiology of ascites.[3]
| Portal hypertension | |||||||||||||||||||||||||||||||||||||||||||||||
| Vasodilator release | |||||||||||||||||||||||||||||||||||||||||||||||
| Splanchnic arteriolar vasodilation | |||||||||||||||||||||||||||||||||||||||||||||||
| Splancnic hypertension | Beta blockers | ||||||||||||||||||||||||||||||||||||||||||||||
| Hypovolemia and Arterial hypotension | |||||||||||||||||||||||||||||||||||||||||||||||
| Sympathetic nerve activation | |||||||||||||||||||||||||||||||||||||||||||||||
| Renin-angiotensin-aldosterone system activation | Aldosterone antagonists | ||||||||||||||||||||||||||||||||||||||||||||||
| Vasopressin activation | |||||||||||||||||||||||||||||||||||||||||||||||
| Increased lymph formation | |||||||||||||||||||||||||||||||||||||||||||||||
| Sodium and water retention | Loop diuretics | ||||||||||||||||||||||||||||||||||||||||||||||
| Paracentesis | |||||||||||||||||||||||||||||||||||||||||||||||
| Plasma volume expansion | |||||||||||||||||||||||||||||||||||||||||||||||
| Ascites | |||||||||||||||||||||||||||||||||||||||||||||||
Dietary salt and water intake restriction
- Limitation of daily sodium intake results in negative sodium balance and also redistribution of fluid retention.
- Daily avoidance of prepared foods along with no added salt diet would lead to suitable sodium restriction (80–120 mMol, corresponded to 4.6–6.9 grams of salt/day).
- Water restriction is the absolute therapy for fluid accumulation in uncomplicated ascites. However, decreasing water input to <1 L/day is almost impossible in some patients.[4]
Ascites
- 1 Grade I
- No treatment is needed.
- 2 Grade II
- 2.1 Adult
- The goal is weight loss of no more than 1.0 kg/day for patients with both ascites and peripheral edema and no more than 0.5 kg/day for patients with ascites alone.[5]
- Preferred regimen (1): Spironolactone 100 mg PO daily until adequate natriuresis (max. dose of 400 mg)
- Preferred regimen (2): Furosemide up to 160 mg PO daily
- Alternative regimen (1): Potassium canrenoate 200 mg PO daily
- Alternative regimen (2): Amiloride 10-40 mg PO daily
- 2.2 Pediatric[6]
- Preferred regimen (1): Spironolactone 2-3 mg/kg PO as a single morning dose (max. dose 2 mg/kg every 5-7 days)
- Preferred regimen (2): Furosemide up to 1 mg/kg PO daily (max. dose 40 mg)
- Preferred regimen (3): Albumin 25% up to 1 g/kg IV daily, up to q8h (until plasma level > 2.5 g/dL)
- 3 Grade III
- Paracentesis followed by salt restriction and diuretics
- 4 Refractory
References
- ↑ 1.0 1.1 1.2 Runyon, BA. "Management of adult patients with ascites due to cirrhosis: update 2012" (PDF).
- ↑ "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J. Hepatol. 53 (3): 397–417. 2010. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
- ↑ Pedersen JS, Bendtsen F, Møller S (2015). "Management of cirrhotic ascites". Ther Adv Chronic Dis. 6 (3): 124–37. doi:10.1177/2040622315580069. PMC 4416972. PMID 25954497.
- ↑ Ginès P, Cárdenas A (2008). "The management of ascites and hyponatremia in cirrhosis". Semin. Liver Dis. 28 (1): 43–58. doi:10.1055/s-2008-1040320. PMID 18293276.
- ↑ Shear L, Ching S, Gabuzda GJ (1970). "Compartmentalization of ascites and edema in patients with hepatic cirrhosis". N. Engl. J. Med. 282 (25): 1391–6. PMID 4910836.
- ↑ Giefer, Matthew J; Murray, Karen F; Colletti, Richard B (2011). "Pathophysiology, Diagnosis, and Management of Pediatric Ascites". Journal of Pediatric Gastroenterology and Nutrition. 52 (5): 503–513. doi:10.1097/MPG.0b013e318213f9f6. ISSN 0277-2116.