principles of management of ascites combined
TRANSCRIPT
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PRINCIPLES OF MANAGEMENT OF ASCITES
Richard Warner
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• Causes of Ascites
• Management of ‘Simple Ascites’
• Management of ‘Refractory Ascites’
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Causes of Ascites- Normal Peritoneum
SAAG >11g/l• Cirrhosis
• 10th cause
of death in
USA
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Causes of Ascites- Normal Peritoneum
SAAG >11g/l
• Cirrhosis• Portal Hypertension • Budd Chiari Syndrome• Fulminant Hepatic Failure• Massive Hepatic Metastases• Accounts for ~85% Ascites
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Causes of Ascites- Normal Peritoneum
SAAG >11g/l
• Hepatic Congestion• Constrictive Pericarditis• Congestive Heart Failure• Tricuspid Insufficiency
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Causes of Ascites-Normal Peritoneum
SAAG < 11g/lHypoalbuminaemia
• NEPHROTIC SYNDROME
• PROTEIN LOSING ENTEROPATHY
• SEVERE MALNUTRITION
Miscellaneous
• CHYLOUS ASCITES
• PANCREATITIS ASCITES
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Causes of Ascites-Diseased Peritoneum
SAAG < 11g/l
• Bacterial, Fungal, TB, HIV Related Infections
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Causes of Ascites-Diseased Peritoneum
SAAG < 11g/l
• Malignant – Peritoneal, Pseudomyxoma Peritonei, Primary Mesothelioma, Hepatocellular Carcinoma
• Rare – Familial Mediterranean Fever, Vasculitis , Eosinophilic Peritonitis, Granulomatous Peritonitis
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•
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Ascites is not just a Cosmetic Problem !
• Median Survival 2 years from onset
• Survival depends mainly on Liver Function
• SBP occurs ~25%• Low urinary Na+ &
SBP predict high mortality
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Management of Ascites-Guidelines
• International Ascites Club (Hepatology 2003/2004) – supported by unconditional educational grant from Seale, Spain
• American Association for the Study of Liver Disease (AASLD) – Hepatology March 2004.
• 50 % of patients diagnosed with cirrhosis, develop ascites in 10 years.
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Management
Treat the Underlying Cause
• Alcohol has best prognosis if abstain
• Childs C – 75% 3-year survival Vs. 0%
• Non-Alcoholic less reversible therefore consider referral for transplant earlier
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Treatment Options
• Bed rest• Diet• Diuretics• Fluid Restriction• Paracentesis• TIPSS• Shunts• Transplant
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Ascites- Grading
• Grade 1 – Ultrasound detected• Grade 2 moderate – symmetrical distension of
abdomen• Grade 3 – tense or gross ascites• (Refractory ascites (5 –10% of all ascites))
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Management of ascites-Bed Rest
Bed rest : No clinical trials• Upright posture activates sodium retaining
mechanisms , impairs renal perfusion and sodium excretion.
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Management of ascites-Sodium Restriction
Sodium restriction : Water will follow Sodium Educate the Patient Aim for 2000mg (88 mmol) per day Studies show severe restriction (22mmol/day) compared
with less restricted is associated with longer duration of evolution of ascites, but higher incidence of diuretic induced renal impairment and hyponatraemia (Gauthier 1986 , Reynolds 1978)
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MANAGEMENT OF ASCITES- Salt restriction (cont)
• One controlled study, showed slightly reduced salt diet (120mmol/day) was equally effective when compared to a low salt diet ( 50mmol/day).
• No significant survival difference, although low salt diet (50mmol/day ) improved survival in those with previous GI bleed
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MANAGEMENT OF ASCITES-
WATER RESTRICTION• Central hypovolaemia - > stimulates ADH receptors - > decreases free water clearance - > dilutional
hyponatraemia. • Therefore, treat by water restriction – no trials to assess
effect of water restriction in patients with cirrhosis and dilutional hyponatraemia. Restriction may worsen central hypovolaemia.
• Water restriction not first option, sodium restriction appropriate first line, water restrict if Na <125mmol/L
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MANAGEMENT OF ASCITES-
DIURETICS
• Antimineralocorticoids –
Secondary hyperaldosteronism promotes sodium retention in distal tubules and collecting ducts
Controlled and uncontrolled trials - > Spironolactone effective antimineralocorticoid
• S.E gynaecomastia, renal impairment, hyperkalaemia
• Other K sparing diuretics: amiloride, triamterene
• Loop Diuretics : Frusemide – S.E : hyponatraemia, hypokalaemia, hypovolemia, renal impairment of prerenal origin
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ASCITES-Assess response to diuretics :
• Weight loss of 0.5kg/day in absence of oedema and 1kg/day when oedema present
• Use Spironolactone & Frusemide 100mg/40mg ratio
• Medical treatment based on sodium restricted diet, diuretics – response in 90 % without renal failure in controlled trials (Bernadi 95, Gatta ’91)
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Ascites-Paracentesis
• Repeated daily paracentesis ( 5L/day )
• Single total paracentesis- reduced hospital stay
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Ascites-Paracentesis
• 5 randomised controlled trials comparing paracentesis to diuretics : more effective, shortened duration of hospitalisation, fewer complications
• Paracentesis should be followed by maintenance diuretics
• Ascites recurred in 4/52 postparacentesis in 18 % of patients receiving diuretics vs. 93 % receiving placebo (Fernandez –Gsparrach 1997)
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Paracentesis-Systemic Effects
• Acute increase of cardiac output, lowering of systemic vascular resistance - > modest reduction of blood pressure.
• Pulmonary capillary pressure reduces 6 hours postparacentesis, right atrial pressure falls acutely sec to reduced intrathoracic pressure.
• Hypovolemia occurs – therefore volume expanders used• Gines et al –randomised controlled trial of repeat
paracentesis - patients received albumin or placebo• S.E in 30 % not receiving albumin vs. 16 % receiving
albumin• SE were renal impairment, hyponatraemia, elevation of
plasma renin and aldosterone levels
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Paracentesis
• Volume expander : albumin vs. synthetic expanders.
• Albumin – expensive, risk of infection with non- eradicated viruses and prion related infections
• Practice guidelines committee of American association for study of liver disease have challenged use of albumin in view of this
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Ascites-Refractory Ascites
• Unresponsive to Salt restriction & high dose diuretics (400mg Spironolactone & 160mg Frusemide)
• Recurs rapidly after Paracentesis (< 4/52)• Diuretic induced complication – encephalopathy,
renal impairment, hyponatraemia (<125mmol/L), hypo (3mmol/L) or hyperkalaemia (6mmol/L)
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Refractory Ascites-Treatment Options
• Serial Paracentesis• Liver Transplantation• TIPSS• Peritoneovenous Shunts
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Refractory Ascites-Treatment Options
Serial Paracentesis• Safe• Gives insight into patient salt compliance• Ascitic Na similar to serum• 6L Ascites(780mmol Na) = 10 days intake• Cost, Inconvenience & Infections are main
disadvantages
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Refractory Ascites-Treatment Options
Liver Transplantation
• Once refractory 50% mortality @ 6/12 and 75% mortality @ 1 year
• Referral often delayed
• ? Suitability of patients?
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Refractory Ascites-Treatment Options
Peritoneovenous Shunts• Popular in 1970s• LeVeen or Denver• Poor long term patency• No Survival advantage• Make Transplantation difficult• Use now limited to palliation
in rural areas
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Refractory Ascites-Treatment Options
TIPSS
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TIPSS
• Shunt between hepatic vein (low pressure) and portal vein (high pressure)
• Improvement of renal function and sodium excretion
• Resolution of ascites
• Effect on circulatory system : increase in cardiac output, right atrial pressure and pulmonary arterial pressure with secondary decrease of systemic vascular resistance. Increase in effective arterial blood volume
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TIPS vs. ParacentesisStudy No.
PatientsControl of Ascites
Survival 1 Year
Encephalopathy
Rossle et al NEJM, 2000
60 61% vs.18% p=.006
69% vs. 52%
58% vs.48 %
Gines et al Gastroenterology, 2002
70 51% vs. 17% p=.003
41% vs. 35%
60% vs. 34%
Sanyal et al Gastroenterology 2003
109 58% vs. 16% p<.001
40% vs. 37%
38% vs. 12%
Salerno et al Hepatology 2002
57 74% vs.35% p=.008
71% vs. 35%
55% vs. 46%
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TIPS- Complications
• Capsule rupture• Intra- abdominal bleeding• 70% shunt stenosis in 6 months- recurrence of ascites• Encephalopathy- risk increased in those with pre-TIPS
encephalopathy and age >60yrs• Risk of cardiac failure in those with underlying cardiac
disease due to sudden increase in cardiac preload• Liver function deteriorates significantly post TIPS –
secondary shunting of blood from liver
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ASCITES MX
• GRADE 1: no specific treatment, adv re: reduced salt intake
• Grade 2 : dietary sodium restriction (2000mg /day/ 88mmol/day)
• Diuretics
• Grade 3 : Paracentesis 8g of albumin with 1L of ascitic fluid drained, maintenance diuretics
• Refractory : Repeat paracentesis, diuretics as tolerated – stop if complications or urine Na <30mmol/day. If >3 paracentesis/month, consider TIPS or liver transplant.
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Any Questions?
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TIPS VS PARACENTESIS
• 3) 49 % of patients with TIPS- recurrent ascites
83 % with paracentesis –recurrent ascites
Higher risk of encephalopathy and cost in TIPS
no survival rate difference
(Gines P 2002)
4) North American multicentre trial with 109 pts-
TIPS superior in control of ascites but mean survival equal in both patients
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TIPS VS PARACENTEISIS
1) those with Child C, overall survival worse with TIPS. Therefore contraindicated (Lebreo D 1996)
2) 60 patients with refractory ascites – paracentesis without albumin vs. TIPS (Rossle M 2000)
TIPS – 15 deaths, 1 underwent liver transplantation
Paracentesis – 23 deaths, 2 underwent liver transplant
Probability of survival without transplant 69 % at 1year in TIPS, vs. 52 % in paracentesis. Frequency of encephalopathy similar