Ascites in Cirrhosis

AASLD guidelines 2012

update

Ascites
80% CLD, 5% mixed, 15% other
Important landmark - poor prognosis
19% 1 year mortality
44% 5 year mortality

Diagnosis
Clinically detected when 1500cc is
present
Shifting dullness 83% sensitivity and
56% specificity in detecting ascites.
Confirmation abnormal ultrasound
or paracentesis

Paracentesis
Rapid, cost effective
Can detect and confirm infection
Complications rare bleeding
<1/1000
Higher in the setting of renal impairment
Correction of platelets and INR no proven benefit
hemorrhagic complications despite a) no prophylactic
transfusions, b) platelet counts as low as 19,000 cells/mm3
(19 106/L)(54% <50,000) and c) international normalized
ratios for prothrombin time as high as 8.7 (75% >1.5 and
26.5% >2.0) 1
Grabau, Catherine M., et al. "Performance standards for therapeutic
abdominal paracentesis." Hepatology 40.2 (2004): 484-488.
1

Paracentesis
Site
2 finger
breadths (3 cm)
cephalad and 2
finger breadths
medial to the
anterior
superior iliac
spine

Recommendations
1. Diagnostic abdominal paracentesis should
be performed and ascitic fluid should be
obtained from inpatients and outpatients with
clinically apparent new-onset ascites. (Class I,
Level C)
2. Since bleeding is sufficiently uncommon, the
routine prophylactic use of fresh frozen plasma
or platelets before paracentesis is not
recommended.
(Class III, Level C)

Tests to be performed
Routine : cell count, protein, SAAG
? Infection :
Culture, glucose, LHD, gram stain

? Tuberculosis
Unusual tests: pH, bilirubin,

Recommendations
3.
The
initial
laboratory
investigation of ascitic fluid
should include an ascitic fluid
cell count and differential,
ascitic fluid total protein, and
SAAG.(Class I, Level B)

Recommendations
4. If ascitic fluid infection is suspected,
ascitic fluid should be cultured at the
bedside in aerobic and anaerobic
blood culture bottles prior to initiation
of antibiotics. (Class I, Level B)
5. Other studies of ascitic fluid can be
ordered
based
on
the
pretest
probability of disease (Class IIa, Level
C)

Recommendations
6. Testing serum for CA125 is not
helpful in the differential diagnosis
of ascites. Its use is not
recommended in patients with
ascites of any type. (Class III,
Level B)

Recommendation
9. 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). (Class IIa,
Level A)

Alcohol cessation
Most important
Child Pugh C : 3 year survival
Abstinence 75% vs continuous users 0%

Baclofen

Diuretics

Spiranolactone (100mg)
Furosemide (40mg) risks of IV treatment
Dual therapy
Amiloride (no gynecomastia) less effective
Withheld in the setting of active
gastrointestinal bleeding, hepatic
encephalopathy, Na<120 or renal
dysfunction
Weight loss - rate

Albumin
Therapeutic: An unblinded randomized
controlled trial in patients with new onset
ascites demonstrates that weekly 25 g
infusions of albumin for 1 year followed by
infusions every 2 weeks improved survival
compared to diuretics alone.
With paracentesis: A meta-analysis of 17
trials involving 1225 patients has been
published, demonstating a reduction in
mortality with an odds ratio of death of 0.64
(95% CI, 0.41-0.98) in the albumin group.

Less evidence for

Vasopressin receptor antagonists
Bed rest
Fluid restriction in the absence of
severe hyponatraemia

What to avoid
Blood pressure in patients with cirrhosis
and ascites is supported by elevated
levels of vasoconstrictors; these
vasoconstrictors are compensating for the
vasodilatory effect of nitric oxide
Arterial pressure independently predicts
survival in patients with cirrhosis; those
with a mean arterial pressure (MAP) >82
mmHg have a 1-year survival of 70%,
compared to 40% for those 82 mmHg 1.
Llach J, Gines P, Arroyo V, Rimola A, Tito L, Badalamenti S, Jimenez W, et al. Prognostic value of
arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted
to the hospital for the treatment of ascites. Gastroetnerology 1988;94:482-487.
1

Avoid..
ACEIs and ARBs should be avoided or
used with caution in patients with
cirrhosis and ascites.
Propranolol refractory ascites, RF
NSAIDs Na retention, RF

Special situations
Tense ascites
Single large volume paracentesis
5l without colloids
Thereafter : albumin 8g per liter of fluid
removed

Start other modalities of

treatment ..

Failure of diuretic therapy

(1) Minimal response + inadequate
(<78 mmol per day) urinary Na+
excretion despite diuretics or
(2) development of clinically significant
complications of diuretics
( e.g., encephalopathy, serum creatinine greater than
2.0 mg/dL, serum sodium less than 120 mmol/L, or
serum potassium greater than 6.0 mmol/L)

Refractory ascites
Fuid overload that
(1) is unresponsive to sodium-restricted
diet and high dose diuretic treatment (400
mg per day of spironolactone and 160 mg
per day furosemide), or
(2) recurs rapidly after therapeutic
paracentesis

Refractory ascites - Rx

Stop beta blcokers

Midodrine
TIPS
Serial paracentesis
Peritoneovenous shunt

Thank you