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Guidelines on
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pyelonephritis practice profile
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CPD hepatology
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or tenderness, guarding or tensing of the deterioration in health (Sargent 2009).
abdomen followed by percussion. A multidisciplinary team approach to the
Percussion can detect an accumulation of management of patients with ascites is
1,000-1,500mL of fluid in the peritoneal ideal to address mobility issues, optimal
cavity. Percussion is carried out with the medical treatment, patient education and
patient in two positions. First, with the psychological support.
patient in the supine position, free fluid in
the abdomen moves with gravity and will FIGURE 1
collect around the flanks. Percussion,
therefore, reveals dullness in the flanks and Pathophysiology of ascites
tympanic sounds at the top of the abdomen
where air has accumulated. Second, the Increased pressure
patient is positioned on his or her side. Now in the portal vein
the fluid moves with gravity to the front of the
abdomen, allowing the air to be percussed
at the top by the flank. This is known as the
assessment of shifting dullness (Rushing Sodium and water Production of nitric
2005) (Figure 2), and can be done by a retention oxide causing dilation of
the abdominal vessels
nurse with advanced assessment skills or
a medical practitioner.
Once fluid has been detected and the
ascites graded, it is important to confirm
that the ascites is occurring as a result of Renin-angiotensin- Increased blood flow in
liver dysfunction. As previously mentioned, aldosterone activation the abdominal vessels
there are other causes of ascites and it is
important to rule these out before treatment
options are considered.
A 30mL sample of ascitic fluid should be Reduced blood flow
to major organs
aseptically obtained by a medical practitioner,
10mL of which should be tested for white
and red blood cell counts and albumin
concentration. Table 2 shows the rationale TABLE 1
for testing these parameters. The remaining
20mL of ascitic fluid is sent for culture and Grading of ascites
sensitivity testing. If infection is present, this Grade Detection technique Abdominal distension
will indicate which organism is responsible and
1 Ultrasound Absent (<500mL of fluid)
the appropriate antibiotic therapy.
2 Inspection, palpation Moderately distended
and percussion
Psychological effects 3 Inspection, palpation Grossly or markedly
The psychological needs of patients with and percussion distended
ascites are important yet are often neglected (Adapted from European Association for the Study of the Liver 2010)
because of the prioritisation of medical
needs. The complications of and treatments
for chronic liver disease can lead to lethargy, FIGURE 2
depression and reduced quality of life (Mucci
Assessment of shifting dullness
et al 2013). The complications of end-stage
JO CAMERON
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CPD hepatology
TABLE 2
Ascitic fluid analysis
Parameter Rationale Explanation
2 Aldosterone White cell count Presence of >250 white blood If the fluid is drained when infection is
antagonists and loop cells/mm3 indicates infection. present, septicaemia may occur.
diuretics are two groups Red cell count Presence of red blood cells Fluid in the abdomen can tamponade
of diuretics commonly indicates bleeding within the bleeding. If the fluid is drained, the bleeding
used in the treatment peritoneal cavity. point may haemorrhage further as the
of grade 2 ascites. Can pressure pushing against it would decrease.
you name at least one Albumin content Comparing the serum albumin Serum ascites albumin gradient >11g/L
diuretic that falls in each with the ascitic albumin (>1.1g/dL) indicates the ascites is present
category and outline content indicates the cause of because of liver disease.
their specific mode of ascites.
action? (Moore and Aithal 2006, Runyon 2013)
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TABLE 3
Complications of ascites
Complications Symptoms Treatments
Spontaneous Abdominal pain, fever. May be asymptomatic. Antibiotic administration. Large-volume paracentesis
bacterial peritonitis should be withheld until infection is treated effectively.
Dilutional Increased peripheral oedema and Fluid restriction may be instigated if sodium is
hyponatraemia re-accumulation of ascites. <130mmol/L, but should be used with caution.
Hepatorenal Reduced renal function, raised creatinine in the Administration of the vasoconstrictor terlipressin in
syndrome absence of infection, shock or use of nephrotoxic combination with albumin. Liver transplantation.
drugs.
Pleural effusion Shortness of breath, increased respiratory rate, Chest drains are contraindicated for this cause of
reduced air entry. pleural effusion. First-line treatment includes diuretic
administration and reduced sodium diet.
Umbilical hernia Swelling of the area around the umbilicus. May require surgical intervention depending on the
May be associated with abdominal pain or severity of the hernia.
discomfort.
(Adapted from European Association for the Study of the Liver 2010, Garcia-Tsao 2011, Runyon 2013)
Diuretics are used in conjunction with a reduced a reduction in sodium excretion and a
salt diet to increase the excretion of sodium via reduced response to diuretics (Bacon et al
the kidneys. Aldosterone antagonists are more 2006). However, there is no evidence to
effective than loop diuretics in the management support the relationship between bed rest
of ascites because they treat the pathophysiology and the effectiveness of diuretics; therefore,
of the accumulation of ascites as well as complications of bed rest must be considered
preserving potassium levels. Patients with a first (Moore and Aithal 2006). Bed rest may lead
episode of ascites should receive an aldosterone to muscular atrophy, constipation, increased
antagonist such as spironolactone at doses of risk of deep vein thrombosis and prolonged
between 100mg and 400mg daily (Rosner et al hospital stay.
2006). The maximum recommended weight Fluid restriction as a standard treatment
loss during diuretic therapy should be 0.5kg is not advisable, and there are no studies
daily in patients without peripheral oedema and proving its efficacy in the management of
1kg daily in patients with peripheral oedema ascites (Runyon 2013). Fluid restriction
(EASL 2010). In patients who do not respond may exacerbate the severity of central
to aldosterone antagonists, which means a hypovolaemia, which may increase the
reduction of body weight of less than 2kg per secretion of antidiuretic hormone and result in
week, or if the patient develops hyperkalaemia a further deterioration in renal function. Fluid
or recurrent ascites, a loop diuretic such as restriction may be recommended if dilutional
furosemide should be added to the treatment hyponatraemia of less than 130mmol/L is
regimen at a dose of 40-160mg daily (Runyon present; however, it must always be used with
2013). Patients should be monitored frequently caution (Garcia-Tsao 2011).
for clinical and biochemical parameters, Large-volume paracentesis is the insertion
particularly during the first month of treatment. of a catheter into the peritoneal cavity to drain
Side effects of diuretics include renal failure, the fluid and is the first-line therapy in patients
hepatic encephalopathy, electrolyte disorders, with large or grade 3 ascites. It is usually
gynaecomastia and muscle cramps (British performed by a medical practitioner and can be
National Formulary 2013). Monitoring should, undertaken in an outpatient setting; however,
therefore, include electrolyte balance, renal ascites may re-accumulate quickly and require
function and assessment for signs of hepatic further drainage. There is no indication
encephalopathy. that coagulation or platelet count should be
Bed rest with legs elevated is advocated by corrected before this procedure because the risk
Alexander et al (2006) as the most comfortable of bleeding is low (Pache and Bilodeau 2005).
position and is likely to reduce peripheral Large-volume paracentesis should be
oedema. The adoption of an upright position performed using an aseptic technique by pulling
has been linked with activation of the the skin down, holding it firmly and inserting
renin-angiotensin-aldosterone system, the paracentesis catheter the Z-track technique
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JO CAMERON
The nurse should be present to ensure the patient
is comfortable and understands the procedure.
Vital signs monitoring must be performed before
the procedure to establish a baseline and then
every 15-30 minutes to assess cardiovascular
stability (Sargent 2009). A complication of
large-volume paracentesis is post-paracentesis
circulatory dysfunction, which manifests as a
low blood pressure, a high heart rate (Salerno
et al 2010) and rapid re-accumulation of ascites
(EASL 2010).
The fluid is then drained via the catheter
continuously over four to six hours. The drain
should not be clamped during this time because
of the increased risk of infection (Sargent
2009). Fluid replacement is required to
prevent cardiovascular complications.
Studies have examined the most effective b) Place paracentesis catheter
fluid to administer for paracentesis, and a
meta-analysis of randomised controlled trials
found that albumin was the most effective
plasma expander in this patient population
(Bernardi et al 2012). Albumin should be
administered at a ratio of 100mL 20% human
albumin solution for every 2-3L of ascites
drained (Moore and Aithal 2006, EASL
2010). In patients undergoing large-volume
paracentesis of 5L or less of ascites, the risk
of developing post-paracentesis circulatory
dysfunction is low and, therefore, evidence
suggests that volume replacement is not
required (Moore and Aithal 2006, EASL
2010). In clinical practice, however, albumin
is often administered for every 2-3L of ascites
drained regardless of the total volume drained
to minimise cardiovascular complications. c) Release tissues
Once the paracentesis catheter is removed,
a dry dressing can be applied over the insertion
site if there is no fluid leaking. If the Z-track
method of insertion is not used, a stoma
collection bag is often required because of
persistent leakage of ascitic fluid from the
paracentesis site (Sargent 2009).
Complete time out activity 3
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daily weights will also show the volume of fluid the TIPSS has been found to be more effective
lost. It is important that patients are weighed than large-volume paracentesis in preventing
at the same time each day with the same recurrence of ascites in randomised comparative
clothes to obtain accurate readings. Pain scores trials, it is associated with a much higher risk of
should be obtained before draining ascites severe encephalopathy (Riggio et al 2008).
and reassessed throughout the procedure. In A stent reduces the pressure in the portal
addition, patients should be encouraged to vein but also reduces the amount of blood
report any abdominal discomfort or bleeding passing through the liver for detoxification.
around the paracentesis site. Some blood will, therefore, return to the
Complete time out activity 4 heart with raised levels of toxins from the
gut, including ammonia. This is one of the
Contraindicated drugs hypothesised causes of hepatic encephalopathy
Non-steroidal drugs are contraindicated (Houlston and ONeal 2009) and raised levels
in patients with ascites because of the in the blood can lead to neurological changes
increased risk of developing further sodium associated with hepatic encephalopathy.
retention, hyponatraemia, and renal failure Despite the relative success of the TIPSS, it
(Hampel et al 2001). Drugs that decrease may not be suitable for all patients (Moore and
arterial pressure or renal blood flow such as Aithal 2006).
angiotensin-converting enzyme inhibitors and
angiotensin-II receptor antagonists should be Implanted automated pump system
avoided because of the increased risk of renal The automated pump system is surgically
impairment (Hampel et al 2001). The use implanted subcutaneously, and it draws
of aminoglycoside antibiotics, for example ascitic fluid from the abdominal cavity to
gentamicin, is associated with an increased the bladder where it is excreted through
risk of renal failure (Garcia-Tsao 1998) and normal urination (Bellot et al 2013). Excess
should be used with caution and in association abdominal fluid is drawn automatically and
with regular monitoring of creatinine levels in continually into the bladder. The speed and
patients with ascites. quantity of fluid removal may be adjusted
to the clinical and social requirements of
the individual patient. This system helps to
Management of refractory ascites reduce the need for repeat paracentesis.
Refractory ascites refers to ascites that does A study of 40 patients with refractory ascites
not respond to medical management or who received an implanted pump showed 3 As the nurse caring
re-accumulates immediately after treatment, that 90% of ascites was removed and the for a patient undergoing
or in patients for whom medical treatment cannot need for large-volume paracentesis was large-volume
be given because of untoward side effects such as reduced. However, there were a large number paracentesis, what
muscle cramps or severe electrolyte imbalance. of complications associated with both the observations would
Treatment options available for refractory insertion procedure and the system itself, you make to ensure the
ascites include large-volume paracentesis for example infection and bladder catheter patients comfort and
with administration of albumin, transjugular dislocation (Bellot et al 2013). There safety, and why?
intrahepatic portosystemic shunt (TIPSS), are larger studies underway looking
implanted automated pump system insertion at the efficacy of the implanted 4 Drugs that impair
and liver transplantation. automated pump system in comparison renal function should
to large-volume paracentesis. be avoided in patients
Transjugular intrahepatic portosystemic shunt with ascites because
A TIPSS is the insertion of a mesh stent between Liver transplantation the kidneys may become
the portal vein and the hepatic vein. This Patients with refractory ascites should be injured as a result of the
assists in reducing the pressure in the portal considered for liver transplantation because constant need to retain
vein and reduces the accumulation of ascites their median survival is approximately six salt and water and
(Sargent 2009). The TIPSS has been found to months (EASL 2010). At this advanced stage the reduced perfusion
be successful at controlling refractory ascites of liver disease, transplantation is the only pressure. Make a list
in 75% of cases (Riggio et al 2008). It has option. Garcia-Tsao (2011) recommended of the drugs commonly
also been linked to a decrease in activation of early assessment, before further complications used in your clinical area
the renin-angiotensin-aldosterone system and cause deterioration in the patients condition, and find out if any of
improved nutritional state because of reduced which may limit his or her suitability these have nephrotoxic
pressure on the stomach and gastrointestinal for surgery. Because ascites marks the side effects.
tract (Riggio et al 2008). However, although change from compensated liver disease to
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CPD hepatology
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