1 Management of Ascites Management of Ascites I have no disclosures to make relative to my presentation. I have no disclosures to make relative to my presentation. Guadalupe García-Tsao, MD Professor of Medicine Yale University Chief, Digestive Diseases Section VA-CT Healthcare System Guadalupe García-Tsao, MD Professor of Medicine Yale University Chief, Digestive Diseases Section VA-CT Healthcare System Cirrhosis Heart failure Heart failure Peritoneal tuberculosis Peritoneal tuberculosis Cirrhosis is the Most Common Cause of Ascites Cirrhosis is the Most Common Cause of Ascites Others Pancreatic Budd-Chiari syndrome Nephrogenic ascites Others Pancreatic Budd-Chiari syndrome Nephrogenic ascites Peritoneal malignancy Peritoneal malignancy CIRRHOSIS IS THE MOST COMMON CAUSE OF ASCITES Source of the main 3 causes of ascites Source of the main 3 causes of ascites Entity Source Pathophysiology Cirrhosis Hepatic sinusoid Heart failure Hepatic sinusoid Congestion of liver due to right heart failure (post- hepatic block) Peritoneal malignancy/TB Peritoneum Inflammation or infiltration of the peritoneum Patients with cirrhotic ascites have an HVPG of at least 12 mmHg (nl 3-5) Morali et a. J Hepatol 2002
12
Embed
Management of Ascites · SERUM-ASCITES ALBUMIN GRADIENT (SAAG) AND ASCITES PROTEIN LEVELS IN THE MOST COMMON CAUSES OF ASCITES SAAG is an indicator of sinusoidal pressure. If >1.1
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Management of AscitesManagement of Ascites
I have no disclosures to make relative to my presentation. I have no disclosures to make relative to my presentation.
Guadalupe García-Tsao, MDProfessor of Medicine
Yale University
Chief, Digestive Diseases SectionVA-CT Healthcare System
Guadalupe García-Tsao, MDProfessor of Medicine
Yale University
Chief, Digestive Diseases SectionVA-CT Healthcare System
Cirrhosis Heart failureHeart failure
Peritoneal tuberculosisPeritoneal tuberculosis
Cirrhosis is the Most Common Cause of AscitesCirrhosis is the Most Common Cause of Ascites
Spironolactone is More Effective Than Furosemide in Uncomplicated AscitesSpironolactone is More Effective Than Furosemide in Uncomplicated Ascites
Response No response Total
Spironolactone 18 1 19(150-300 mg/d)
Response No response Total
Spironolactone 18 1 19(150-300 mg/d)
Perez-Ayuso et al. Gastroenterology 1983; 84:961 Perez-Ayuso et al. Gastroenterology 1983; 84:961
SPIRONOLACTONE IS MORE EFFECTIVE THAN FUROSEMIDE IN CIRRHOTIC PATIENTS WITH ASCITESSPIRONOLACTONE IS MORE EFFECTIVE THAN FUROSEMIDE IN CIRRHOTIC PATIENTS WITH ASCITES
Large volume-paracentesis (LVP):• Local therapy• Recurrence of ascites is the rule• May be associated with post-paracentesis circulatory dysfunction
8
LVP Without Albumin Leads to Increases in Renin, Renal Failure and HyponatremiaLVP Without Albumin Leads to Increases in Renin, Renal Failure and Hyponatremia
Gines et al., Gastroenterology 1988; 94:1493Gines et al., Gastroenterology 1988; 94:1493
LVP WITHOUT ALBUMIN LEADS TO INCREASES INCIDENCE OF POST-PARACENTESIS CIRCULATORY DYSFUNCTION (PCD)
Consequences of post-paracentesis circulatory dysfunction (PCD)
Consequences of post-paracentesis circulatory dysfunction (PCD)
Shorter time to ascites recurrence
Higher incidence of hyponatremia and renal dysfunction
Higher mortality
Shorter time to ascites recurrence
Higher incidence of hyponatremia and renal dysfunction
Higher mortality
Gines et al., Gastroenterology 1996; 111:1002; Ruiz del Arbol et al., Gastroenterology 1997; 113:579 Gines et al., Gastroenterology 1996; 111:1002; Ruiz del Arbol et al., Gastroenterology 1997; 113:579
CONSEQUENCES OF POST-PARACENTESIS CIRCULATORY DYSFUNCTION (PCD)
Post-paracentesis circulatory dysfunction (PCD) is lowest in patients receiving albumin after LVPPost-paracentesis circulatory dysfunction (PCD) is lowest in patients receiving albumin after LVP
Development of PCD
Development of PCD
%%
Ascites removedAscites removedOverallOverall <5-6 L<5-6 L >5-6 L>5-6 L
7070
6060
5050
4040
3030
2020
1010
00
No expanderSalineSynthetic expanderAlbumin*
No expanderSalineSynthetic expanderAlbumin*
Gines et al., Gastroenterology 1988; 94:1493; Gines et al., Gastroenterology 1996; 111:1002;Sola-Vera et al., Hepatology 2003; 37:1147
Gines et al., Gastroenterology 1988; 94:1493; Gines et al., Gastroenterology 1996; 111:1002;Sola-Vera et al., Hepatology 2003; 37:1147
*6-8 g per liter of ascites removed*6-8 g per liter of ascites removed
In refractory ascites, TIPS is more effective than LVP in preventing ascites recurrence In refractory ascites, TIPS is more effective than LVP in preventing ascites recurrence
D’Amico et al. Gastroenterology 2005; 129:1282D’Amico et al. Gastroenterology 2005; 129:1282
Odds ratioOdds ratio
Salerno et al. Gastroenterology 2007;133:825–834Salerno et al. Gastroenterology 2007;133:825–834
In a meta-analysis of individual patient data, survival was better with TIPS than LVP
In a meta-analysis of individual patient data, survival was better with TIPS than LVP
SurvivalSurvival EncephalopathyEncephalopathy
P=0.005
p=0.36
Greater survival benefit in patients treated with TIPS who had a MELD
score <15
Greater survival benefit in patients treated with TIPS who had a MELD
A trial of in-hospital diuretic therapy should be attempted
Serial thoracenteses – may be required too frequently
Chest tube or indwelling catheter should not be placed ( infection, AKI)
TIPS may need to be considered earlier Clinical response (67%) and survival are
also associated with pre-TIPS MELD <15
A trial of in-hospital diuretic therapy should be attempted
Serial thoracenteses – may be required too frequently
Chest tube or indwelling catheter should not be placed ( infection, AKI)
TIPS may need to be considered earlier Clinical response (67%) and survival are
also associated with pre-TIPS MELD <15
Dhanasekaran et al. Am J GE 2010.
Peritoneo-Venous Shunt (PVS) is Useful in the Treatment of Refractory Ascites
Use of jugular vein will hinder TIPS placement
Use of jugular vein will hinder TIPS placement
Intraabdominal adhesions may complicate liver
transplant surgery
Intraabdominal adhesions may complicate liver
transplant surgery
One-way valve
One-way valve
Indicated in malignant ascites or patients who are not transplant or TIPS
candidates
ALFA pump transfersascites into the bladder
Pilot safety study of Automated Low-Flow pump for refractory Ascites (ALFA) (n=40)Pilot safety study of Automated Low-Flow pump for refractory Ascites (ALFA) (n=40)
Placed under general anesthesia
6-month followup
LVP 3.4 0.2 per month
Infections antibiotic prophylaxis (76%42%)
Catheter dislodgement/problems (10/40=25%)
Surgical complications (5/40)
Progressive decrease in serum albumin
13 early termination, 8 died, 2 txp
Placed under general anesthesia
6-month followup
LVP 3.4 0.2 per month
Infections antibiotic prophylaxis (76%42%)
Catheter dislodgement/problems (10/40=25%)
Surgical complications (5/40)
Progressive decrease in serum albumin
13 early termination, 8 died, 2 txp
Bellot et al. J Hepatol 2013;58:922-7
12
Hernandez-Gea et al. Am J Gastroenterol 2012; 107:418-27Hernandez-Gea et al. Am J Gastroenterol 2012; 107:418-27
In patients with large varices that have not bled, a decrease in HVPG >10% leads to less ascites, RA and HRS
Ascites
Hepatorenalsyndrome
Refractory ascites
Cirrhotic ascitesCirrhotic ascites
The most common decompensating event in cirrhosis
It is not an emergency unless complicated by infection or hepatorenal syndrome
Ideal treatment strategies should be based on its pathophysiology Increase sodium excretion
Decrease sinusoidal pressure
Remove fluid while replenishing intravascular volume
The most common decompensating event in cirrhosis
It is not an emergency unless complicated by infection or hepatorenal syndrome
Ideal treatment strategies should be based on its pathophysiology Increase sodium excretion
Decrease sinusoidal pressure
Remove fluid while replenishing intravascular volume