Ascites Sadik 21-3-09
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CIRRHOTIC ASCITES DR SADIK MEMON FCPS (MEDICINE), FCPS (GASTROENTEROLOGY), AGA-M ISRA UNIVERSITY HYDERABAD.
NATURAL HISTORY OF CIRRHOSIS
Development of Complications in Compensated Cirrhosis 100 80
Ascites Jaundice Encephalopathy GI hemorrhage
Probability 60 of developing 40 event 20 0 0
20
40
60
80
100
Months Gines et. al., Hepatology 1987; 7:122
120
140
160
Case 1 Dr. Muhammad Sadik Memon Associate Professor / Gastroenterologist Head Section of Gastroenterology & Hepatology Department of Medicine Isra University Hospital
A 35 year old gentleman came to you, with progressive abdominal distension. Palmer erythna Wasting Anemia Shifting dullness positive Splenomegaly Pedal edema
What is your probable diagnosis?
How will treat? 1) RE-assurance 2) Salt- restriction, alternative to salt restriction 3) Water restriction 4) Diuretics.
HVPG > 12 mmHg IS NECESSARY FOR ASCITES TO DEVELOP AND IS ASSOCIATED WITH LOW SODIUM EXCRETION
HVPG > 12 mmHg is Necessary for Ascites to Develop and is Associated with Low Sodium Excretion 60
No ascites Ascites
50 40
Urinary sodium 30 (mEq/L) 20
10 0 0
5
Morali et al., J Hepatol 1992; 16:249
10 12
HVPG (mmHg )
15
20
25
URINARY SODIUM EXCRETION IS DECREASED IN CIRRHOTIC PATIENTS WITH ASCITES
Urinary Sodium Excretion is Decreased in Cirrhotic Patients with Ascites 140 120
Urinary sodium excretion (mmol/day )
100 80 60 40 20 4 0
No ascites
Moderate ascites
Eisenmenger et al, J Clin Invest 1950; 29:1491
Tense ascites
PATHOGENESIS OF ASCITES
Cirrhosis Hepatic venous outflow block
Arteriolar resistance
Sinusoidal pressure
Effective arterial blood volume
(vasodilation)
(HVPG ≥ 10-12 mmHg)
Ascites
Sodium and water retention
Activation of neurohumoral systems (renin, angiotensin, aldosterone)
ULTRASOUND IS THE MOST SENSITIVE METHOD TO DETECT ASCITES
Ultrasound is the Most Sensitive Method to Detect Ascites Ascites
Liver
MECHANISM OF ACTION OF THE DIFFERENT THERAPIES FOR ASCITES
Site of Action of Different Therapies for Ascites
Cirrhosis Arteriolar resistance
Intrahepatic resistance
Sinusoidal TIPS pressure
LVP
PVS
Ascites
(vasodilation)
Albumin Effective TIPS PVS arterial blood volume
Diuretics Sodium and water retention
Activation of neurohumora l systems
PREVENTION OF ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
No specific therapy Consider salt restriction
TREATMENT OF UNCOMPLICATED ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
MECHANISMS OF ACTION OF SODIUM RESTRICTION AND DIURETICS IN THE MANAGEMENT OF ASCITES
Cirrhosis Arteriolar resistance
Intrahepatic resistance
(vasodilation)
Sinusoidal pressure
Diuretics Na restrictiion
Ascites
Sodium Sodiumand and water water retention retention
Effective arterial blood volume Activation of neurohumora l systems
SPIRONOLACTONE IS MORE EFFECTIVE THAN FUROSEMIDE IN CIRRHOTIC PATIENTS WITH ASCITES
Spironolactone is More Effective Than Furosemide in Cirrhotic Patients with Ascites Response No response Total Furosemide
11
10
21
18
1
19
(80-160 mg/d)
Spironolactone (150-300 mg/d)
Perez-Ayuso et al. Gastroenterology 1983; 84:961
DIFFERENT DIURETIC REGIMENS IN PATIENTS WITH CIRRHOTIC ASCITES
Different Diuretic Regimens in Patients with Cirrhotic Ascites Progressive Schedule
Combination Schedule
(n=50)
(n=50)
Spironolactone (SP) 100 → 200 → 400 mg/d
SP 100mg/d + FUR 40mg/d
SP 400mg/d + Furosemide (FUR) 40 → 60 → 80 → 160 mg/d
SP 200mg/d + FUR 80mg/d
4days
4days
SP 400mg/d + FUR 160mg/d
Santos et al., J Hepatol 2003; 39:187
DIFFERENT DIURETIC REGIMENS IN PATIENTS WITH CIRRHOTIC ASCITES
Different Diuretic Regimens in Patients with Cirrhotic Ascites Progressive Schedule
Combination Schedule
(n=50)
(n=50)
Spironolactone (SP) 100 → 200 → 400 mg/d
SP 100mg/d + FUR 40mg/d
SP 400mg/d + Furosemide (FUR) 40 → 60 → 80 → 160 mg/d
SP 200mg/d + FUR 80mg/d
4days
4days
SP 400mg/d + FUR 160mg/d
Santos et al., J Hepatol 2003; 39:187
TREATMENT OF PATIENTS WITH UNCOMPLICATED ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
1) Salt restriction + diuretics 2) Large volume paracentesis (LVP) in hospitalized patients with tense ascites
MANAGEMENT OF UNCOMPLICATED ASCITES
Management of Uncomplicated Ascites Definition: Ascites responsive to diuretics in the absence of infection and renal dysfunction Sodium restriction
• Effective in 10-20% of cases • Predictors of response: mild or moderate ascites, Urine Na excretion > 50 mEq/day
Diuretics • Should be spironolactone-based • A progressive schedule (spironolactone furosemide) requires fewer dose adjustments than a combined therapy (spironolactone + furosemide)
MANAGEMENT OF UNCOMPLICATED ASCITES: SODIUM RESTRICTION
Management of Uncomplicated Ascites Sodium Restriction • 2 g (or 5.2 g of dietary salt) a day • Fluid restriction is not necessary unless there is hyponatremia (<125 mmol/L) • Goal: negative sodium balance • Side effect: unpalatability may compromise nutritional status
MANAGEMENT OF UNCOMPLICATED ASCITES: DIURETIC THERAPY
Management of Uncomplicated Ascites Diuretic Therapy Dosage • Spironolactone 100-400 mg/day • Furosemide (40-160 mg/d) for inadequate weight loss or if hyperkalemia develops • Increase diuretics if weight loss <1 kg in the first week and < 2 kg/week thereafter • Decrease diuretics if weight loss >0.5 kg/day in patients without edema and >1 kg/day in those with edema • Side effects • Renal dysfunction, hyponatremia, hyperkalemia, encephalopathy, gynecomastia
Case
A 45 years old gentleman came to you with altered sleep pattern. His son further added that he is not good at business (Accounting). He does not remember the prices of various goods since 4 days. He is known case of cirrhosis of liver and on diuretics (Furosemide40mg/day and spironolectone 100mg / day). He responded very well and his tummy size decreased very much.
Questions????
Q1. What is the new problems arises in this patient? Q2. Will you continue diuretics? Q3. What laboratory test you will perform?
TREATMENT OF REFRACTORY ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
DEFINITION AND TYPES OF REFRACTORY ASCITES
Definition and Types of Refractory Ascites Occurs in ~10% of cirrhotic patients • Diuretic-intractable ascites 80% Therapeutic doses of diuretics cannot be achieved because of diuretic-induced complications
• Diuretic-resistant ascites 20% No response to maximal diuretic therapy (400 mg spironolactone + 160 mg furosemide/day)
Arroyo et al. Hepatology 1996; 23:164
PATIENTS WITH REFRACTORY ASCITES HAVE A WORSE SURVIVAL THAN PATIENTS WITH DIURETIC-RESPONSIVE ASCITES
Patients with Refractory Ascites Have A Worse Survival than Patients with DiureticResponsive Ascites 1.0 .8
Non refractory ascites Survival probability
.6 .4
p<0.001
.2
Refractory ascites 0
0
12
24
36
48
Months Salerno et al., Am J Gastroenterol 1993; 88:514
60
72
84
MECHANISMS OF ACTION OF LARGE VOLUME PARACENTESIS IN THE MANAGEMENT OF
Cirrhosis Arteriolar resistance
Intrahepatic resistance
(vasodilation)
LVP Sinusoidal pressure
Ascites Ascites
+ Albumin
Sodium and water retention
Effective arterial blood volume Activation of neurohumora l systems
MECHANISMS OF ACTION OF THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT IN THE MANAGEMENT OF ASCITES
Cirrhosis Arteriolar resistance
Intrahepatic resistance
Sinusoidal Sinusoidal pressure pressure
Ascites
(vasodilation)
TIPS
Sodium and water retention
Effective arterial blood volume Activation of neurohumora l systems
COMPARED TO LVP, TIPS IS ASSOCIATED WITH LESS ASCITES RECURRENCE BUT MORE ENCEPHALOPATHY
Compared to LVP, TIPS Reduces Ascites Recurrence But Increases Risk of Encephalopathy LVP p
TIPS
(n=35)
(n=35)
Recurrent ascites
11.7± 2.7* 0.003
3.6 ± 1.7
TIPS obstruction
-
40%
Grade 3-4 PSE
0.5 ± 0.02 0.02 Gines et al., Gastroenterology 2002; 123:1839
1.1 ± 0.02 * Episodes/patient
SURVIVAL IS NOT DIFFERENT BETWEEN PATIENTS TREATED WITH LARGE-VOLUME PARACENTESIS (LVP) OR TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
Survival is Not Different Between Patients Treated With LVP or TIPS 1
Paracentesis and albumin TIPS
0.8
p = 0.51 0.6
Probabilit y of survival
0.4
0.2
0 0
3
6
9
Gines et al., Gastroenterology 2002; 123:1839
12
Months
15
18
21
24
META-ANALYSIS OF TIPS VS. LVP+ALBUMIN FOR REFRACTORY ASCITES
Meta-Analysis of TIPS vs. LVP + Albumin for Refractory Ascites Ascites control (month 4) Ascites control (month 12) Survival (month 12) Encephalopathy More with LVP Deltenre et al., Liver International 2005; 25:349
0
More with TIPS
Risk Differenc e
PERITONEO-VENOUS SHUNT (PVS) IS USEFUL IN THE TREATMENT OF REFRACTORY ASCITES
Peritoneo-Venous Shunt (PVS) is Useful in the Treatment of Refractory Ascites Use of jugular vein will hinder TIPS placement
One-way valve
Intraabdominal adhesions may complicate liver transplant surgery
LARGE VOLUME PARACENTESIS (LVP) VS. PERITONEOVENOUS SHUNT (PVS) IN REFRACTORY ASCITES
Large Volume Paracentesis (LVP) vs Peritoneovenous Shunt (PVS) in Refractory Ascites
Episodes of recurrent ascites PVS obstruction Hospital stay Survival
Gines et al., N Engl J Med 1991; 325:829
LVP
PVS
p value
125
38
<0.001
-
40%
-
48 ± 8
44 ± 6
ns
57%
44%
ns
TREATMENT OF REFRACTORY ASCITES
Treatment of Ascites Portal Hypertension No Ascites Uncomplicat ed Ascites Refractory Ascites
1) LVP + albumin 2) TIPS 3) PVS (in non-TIPS, nontransplant candidates)
Hepatorenal Syndrome
LVP = large volume paracentesis TIPS = transjugular intrahepatic portosystemic shun
ASCITES II A 56 years old lady admitted to the hospital with increasing abdominal pain and fever for three days. She is K/C of HCV cirrhosis decompensated with ascites. On examination she has stigmata of chronic liver disease and tender abdomen. She is vitally stable and febrile.
1. What complication has this patient developed? What is the mechanism? 3. How will you diagnose this complication? 5. What is the treatment of this (immediate and long term)?
SPONTANEOUS BACTERIAL PERITONITIS (SBP) COMPLICATES ASCITES AND CAN LEAD TO RENAL DYSFUNCTION
Spontaneous Bacterial Peritonitis (SBP) Complicates Ascites and Can Lead to Renal Dysfunction
SBP
Portal Hypertension No Ascites
HVPG <10 mmHg Mild Vasodilation
Uncomplicate d Ascites
HVPG >10 mmHg Moderate Vasodilation
Refractory Ascites
Hepatorenal Syndrome
HVPG >10 mmHg Severe Vasodilation
HVPG >10 mmHg Extreme Vasodilation
BACTERIAL INFECTIONS ARE MORE FREQUENT IN SEVERE LIVER DISEASE
Bacterial Infections Are More Frequent in Severe Liver Disease Author Bleichner
n
Child A
Child B
Child C
149
3%
23%
48%
2589
1%
5%
17%
1140
3%
10%
27%
(1986) *
Kuo (1991)
Yoshida (1993)
* patients with GI hemorrhage
SPONTANEOUS BACTERIAL PERITONITIS (SBP) IS THE MOST COMMON INFECTION IN CIRRHOTIC PATIENTS
Spontaneous Bacterial Peritonitis (SBP) is the Most Common Infection in Cirrhotic Patients 150 125 100
# Hospitalize 75 d cirrhotic patients 50 25 0
SBP
UTI
Fernández et al., Hepatology 2002; 35:140
Pneumonia Procedure- Spontaneous related Bacteremia
TYPES OF BACTERIA ISOLATED FROM HOSPITALIZED CIRRHOTIC PATIENTS
Types of Bacteria Isolated from Hospitalized Cirrhotic Patients 100
Culture positive Gram (-) bacteria Gram (+) bacteria Both
80 60
%
40 20 0
SBP
UTI
Fernández et al., Hepatology 2002; 35:140
Pneumoni a
Overall
CLINICAL CHARACTERISTICS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Clinical Characteristics of Spontaneous Bacterial Peritonitis Fever Jaundice Abdominal pain Confusion Abdominal tenderness Hypotension No signs or symptoms 0
20
40
%
60
80
100
MORTALITY ASSOCIATED WITH SBP HAS BEEN DECREASING BY EARLY DIAGNOSIS AND TREATMENT
Mortality Associated with SBP has been Decreasing by Early Diagnosis and Treatment 100 80
% Mortality
60 40 20 0
1970’s
1980’s
Early 90’s Late 90’s
2000’s
EARLY DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Early Diagnosis of SBP • Diagnostic paracentesis: • If symptoms / signs of SBP occur • Unexplained encephalopathy and / or renal dysfunction • At any hospital admission • Diagnosis based on ascitic fluid PMN count >250/mm3 Rimola et al., J Hepatol 2000; 32:142
TREATMENT OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Treatment of Spontaneous Bacterial Peritonitis
• Recommended antibiotics for initial empiric therapy • i.v. cefotaxime , ceftrioxone, amoxicillin-
clavulanic acid • oral ofloxacin (uncomplicated SBP) • avoid aminoglycosides
• Minimum duration: 5 days • Re-evaluation if ascitic fluid PMN count has not decreased by at least 25% after 2 days of treatment Rimola et al., J Hepatol 2000; 32:142
RENAL DYSFUNCTION IS A POOR PROGNOSTIC SIGN IN SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Renal Dysfunction is a Poor Prognostic Sign in Spontaneous Bacterial Peritonitis Renal status Deaths No renal insufficiency
166
12 (7%)
Renal insufficiency
65
27 (42%)
Transient
21
1 (5%)
Stable
26
8 (31%)
Progressive
18
18 (100%)
Follo et al. Hepatology 1994; 20:1945
N
ALBUMIN DECREASES RENAL DYSFUNCTION AND SHORT-TERM MORTALITY IN SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Albumin Decreases Renal Dysfunction and Shortterm Mortality in Spontaneous Bacterial Peritonitis Antibiotics
Antibiotics +
alone (n=63) p
albumin (n=63)
Resolution of SBP
93% ns
98%
Renal dysfunction
32% <0.001
10%
27% Sort et al., N Engl J Med 1999; 341:403 <0.001
10%
Hospital mortality
SPONTANEOUS BACTERIAL PERITONITIS (SBP): USE OF INTRAVENOUS ALBUMIN
Spontaneous Bacterial Peritonitis Use of Intravenous Albumin Albumin (plus antibiotics) is indicated if: • BUN > 30 mg/dL • creatinine > 1.0 mg/dL • bilirubin > 4 mg/dL
Albumin is not indicated in patients with a predicted 100% cure and survival: • • • •
community-acquired SBP no GI hemorrhage no encephalopathy normal renal function
SURVIVAL AFTER DEVELOPMENT OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Survival After Development of Spontaneous Bacterial Peritonitis 1.0 .8 .6
Probability of survival .4 (%) .2 0 0
3
6
12
24
Months Tito et al., Hepatology 1988; 8:27
36
NATURAL HISTORY OF CIRRHOSIS
Development of Complications in Compensated Cirrhosis 100 80
Ascites Jaundice Encephalopathy GI hemorrhage
Probability 60 of developing 40 event 20 0 0
20
40
60
80
100
Months Gines et. al., Hepatology 1987; 7:122
120
140
160
Case 1 Dr. Muhammad Sadik Memon Associate Professor / Gastroenterologist Head Section of Gastroenterology & Hepatology Department of Medicine Isra University Hospital
A 35 year old gentleman came to you, with progressive abdominal distension. Palmer erythna Wasting Anemia Shifting dullness positive Splenomegaly Pedal edema
What is your probable diagnosis?
How will treat? 1) RE-assurance 2) Salt- restriction, alternative to salt restriction 3) Water restriction 4) Diuretics.
HVPG > 12 mmHg IS NECESSARY FOR ASCITES TO DEVELOP AND IS ASSOCIATED WITH LOW SODIUM EXCRETION
HVPG > 12 mmHg is Necessary for Ascites to Develop and is Associated with Low Sodium Excretion 60
No ascites Ascites
50 40
Urinary sodium 30 (mEq/L) 20
10 0 0
5
Morali et al., J Hepatol 1992; 16:249
10 12
HVPG (mmHg )
15
20
25
URINARY SODIUM EXCRETION IS DECREASED IN CIRRHOTIC PATIENTS WITH ASCITES
Urinary Sodium Excretion is Decreased in Cirrhotic Patients with Ascites 140 120
Urinary sodium excretion (mmol/day )
100 80 60 40 20 4 0
No ascites
Moderate ascites
Eisenmenger et al, J Clin Invest 1950; 29:1491
Tense ascites
PATHOGENESIS OF ASCITES
Cirrhosis Hepatic venous outflow block
Arteriolar resistance
Sinusoidal pressure
Effective arterial blood volume
(vasodilation)
(HVPG ≥ 10-12 mmHg)
Ascites
Sodium and water retention
Activation of neurohumoral systems (renin, angiotensin, aldosterone)
ULTRASOUND IS THE MOST SENSITIVE METHOD TO DETECT ASCITES
Ultrasound is the Most Sensitive Method to Detect Ascites Ascites
Liver
MECHANISM OF ACTION OF THE DIFFERENT THERAPIES FOR ASCITES
Site of Action of Different Therapies for Ascites
Cirrhosis Arteriolar resistance
Intrahepatic resistance
Sinusoidal TIPS pressure
LVP
PVS
Ascites
(vasodilation)
Albumin Effective TIPS PVS arterial blood volume
Diuretics Sodium and water retention
Activation of neurohumora l systems
PREVENTION OF ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
No specific therapy Consider salt restriction
TREATMENT OF UNCOMPLICATED ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
MECHANISMS OF ACTION OF SODIUM RESTRICTION AND DIURETICS IN THE MANAGEMENT OF ASCITES
Cirrhosis Arteriolar resistance
Intrahepatic resistance
(vasodilation)
Sinusoidal pressure
Diuretics Na restrictiion
Ascites
Sodium Sodiumand and water water retention retention
Effective arterial blood volume Activation of neurohumora l systems
SPIRONOLACTONE IS MORE EFFECTIVE THAN FUROSEMIDE IN CIRRHOTIC PATIENTS WITH ASCITES
Spironolactone is More Effective Than Furosemide in Cirrhotic Patients with Ascites Response No response Total Furosemide
11
10
21
18
1
19
(80-160 mg/d)
Spironolactone (150-300 mg/d)
Perez-Ayuso et al. Gastroenterology 1983; 84:961
DIFFERENT DIURETIC REGIMENS IN PATIENTS WITH CIRRHOTIC ASCITES
Different Diuretic Regimens in Patients with Cirrhotic Ascites Progressive Schedule
Combination Schedule
(n=50)
(n=50)
Spironolactone (SP) 100 → 200 → 400 mg/d
SP 100mg/d + FUR 40mg/d
SP 400mg/d + Furosemide (FUR) 40 → 60 → 80 → 160 mg/d
SP 200mg/d + FUR 80mg/d
4days
4days
SP 400mg/d + FUR 160mg/d
Santos et al., J Hepatol 2003; 39:187
DIFFERENT DIURETIC REGIMENS IN PATIENTS WITH CIRRHOTIC ASCITES
Different Diuretic Regimens in Patients with Cirrhotic Ascites Progressive Schedule
Combination Schedule
(n=50)
(n=50)
Spironolactone (SP) 100 → 200 → 400 mg/d
SP 100mg/d + FUR 40mg/d
SP 400mg/d + Furosemide (FUR) 40 → 60 → 80 → 160 mg/d
SP 200mg/d + FUR 80mg/d
4days
4days
SP 400mg/d + FUR 160mg/d
Santos et al., J Hepatol 2003; 39:187
TREATMENT OF PATIENTS WITH UNCOMPLICATED ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
1) Salt restriction + diuretics 2) Large volume paracentesis (LVP) in hospitalized patients with tense ascites
MANAGEMENT OF UNCOMPLICATED ASCITES
Management of Uncomplicated Ascites Definition: Ascites responsive to diuretics in the absence of infection and renal dysfunction Sodium restriction
• Effective in 10-20% of cases • Predictors of response: mild or moderate ascites, Urine Na excretion > 50 mEq/day
Diuretics • Should be spironolactone-based • A progressive schedule (spironolactone furosemide) requires fewer dose adjustments than a combined therapy (spironolactone + furosemide)
MANAGEMENT OF UNCOMPLICATED ASCITES: SODIUM RESTRICTION
Management of Uncomplicated Ascites Sodium Restriction • 2 g (or 5.2 g of dietary salt) a day • Fluid restriction is not necessary unless there is hyponatremia (<125 mmol/L) • Goal: negative sodium balance • Side effect: unpalatability may compromise nutritional status
MANAGEMENT OF UNCOMPLICATED ASCITES: DIURETIC THERAPY
Management of Uncomplicated Ascites Diuretic Therapy Dosage • Spironolactone 100-400 mg/day • Furosemide (40-160 mg/d) for inadequate weight loss or if hyperkalemia develops • Increase diuretics if weight loss <1 kg in the first week and < 2 kg/week thereafter • Decrease diuretics if weight loss >0.5 kg/day in patients without edema and >1 kg/day in those with edema • Side effects • Renal dysfunction, hyponatremia, hyperkalemia, encephalopathy, gynecomastia
Case
A 45 years old gentleman came to you with altered sleep pattern. His son further added that he is not good at business (Accounting). He does not remember the prices of various goods since 4 days. He is known case of cirrhosis of liver and on diuretics (Furosemide40mg/day and spironolectone 100mg / day). He responded very well and his tummy size decreased very much.
Questions????
Q1. What is the new problems arises in this patient? Q2. Will you continue diuretics? Q3. What laboratory test you will perform?
TREATMENT OF REFRACTORY ASCITES
Treatment of Ascites Portal Hypertension No ascites Uncomplicated ascites Refractory ascites Hepatorenal syndrome
DEFINITION AND TYPES OF REFRACTORY ASCITES
Definition and Types of Refractory Ascites Occurs in ~10% of cirrhotic patients • Diuretic-intractable ascites 80% Therapeutic doses of diuretics cannot be achieved because of diuretic-induced complications
• Diuretic-resistant ascites 20% No response to maximal diuretic therapy (400 mg spironolactone + 160 mg furosemide/day)
Arroyo et al. Hepatology 1996; 23:164
PATIENTS WITH REFRACTORY ASCITES HAVE A WORSE SURVIVAL THAN PATIENTS WITH DIURETIC-RESPONSIVE ASCITES
Patients with Refractory Ascites Have A Worse Survival than Patients with DiureticResponsive Ascites 1.0 .8
Non refractory ascites Survival probability
.6 .4
p<0.001
.2
Refractory ascites 0
0
12
24
36
48
Months Salerno et al., Am J Gastroenterol 1993; 88:514
60
72
84
MECHANISMS OF ACTION OF LARGE VOLUME PARACENTESIS IN THE MANAGEMENT OF
Cirrhosis Arteriolar resistance
Intrahepatic resistance
(vasodilation)
LVP Sinusoidal pressure
Ascites Ascites
+ Albumin
Sodium and water retention
Effective arterial blood volume Activation of neurohumora l systems
MECHANISMS OF ACTION OF THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT IN THE MANAGEMENT OF ASCITES
Cirrhosis Arteriolar resistance
Intrahepatic resistance
Sinusoidal Sinusoidal pressure pressure
Ascites
(vasodilation)
TIPS
Sodium and water retention
Effective arterial blood volume Activation of neurohumora l systems
COMPARED TO LVP, TIPS IS ASSOCIATED WITH LESS ASCITES RECURRENCE BUT MORE ENCEPHALOPATHY
Compared to LVP, TIPS Reduces Ascites Recurrence But Increases Risk of Encephalopathy LVP p
TIPS
(n=35)
(n=35)
Recurrent ascites
11.7± 2.7* 0.003
3.6 ± 1.7
TIPS obstruction
-
40%
Grade 3-4 PSE
0.5 ± 0.02 0.02 Gines et al., Gastroenterology 2002; 123:1839
1.1 ± 0.02 * Episodes/patient
SURVIVAL IS NOT DIFFERENT BETWEEN PATIENTS TREATED WITH LARGE-VOLUME PARACENTESIS (LVP) OR TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
Survival is Not Different Between Patients Treated With LVP or TIPS 1
Paracentesis and albumin TIPS
0.8
p = 0.51 0.6
Probabilit y of survival
0.4
0.2
0 0
3
6
9
Gines et al., Gastroenterology 2002; 123:1839
12
Months
15
18
21
24
META-ANALYSIS OF TIPS VS. LVP+ALBUMIN FOR REFRACTORY ASCITES
Meta-Analysis of TIPS vs. LVP + Albumin for Refractory Ascites Ascites control (month 4) Ascites control (month 12) Survival (month 12) Encephalopathy More with LVP Deltenre et al., Liver International 2005; 25:349
0
More with TIPS
Risk Differenc e
PERITONEO-VENOUS SHUNT (PVS) IS USEFUL IN THE TREATMENT OF REFRACTORY ASCITES
Peritoneo-Venous Shunt (PVS) is Useful in the Treatment of Refractory Ascites Use of jugular vein will hinder TIPS placement
One-way valve
Intraabdominal adhesions may complicate liver transplant surgery
LARGE VOLUME PARACENTESIS (LVP) VS. PERITONEOVENOUS SHUNT (PVS) IN REFRACTORY ASCITES
Large Volume Paracentesis (LVP) vs Peritoneovenous Shunt (PVS) in Refractory Ascites
Episodes of recurrent ascites PVS obstruction Hospital stay Survival
Gines et al., N Engl J Med 1991; 325:829
LVP
PVS
p value
125
38
<0.001
-
40%
-
48 ± 8
44 ± 6
ns
57%
44%
ns
TREATMENT OF REFRACTORY ASCITES
Treatment of Ascites Portal Hypertension No Ascites Uncomplicat ed Ascites Refractory Ascites
1) LVP + albumin 2) TIPS 3) PVS (in non-TIPS, nontransplant candidates)
Hepatorenal Syndrome
LVP = large volume paracentesis TIPS = transjugular intrahepatic portosystemic shun
ASCITES II A 56 years old lady admitted to the hospital with increasing abdominal pain and fever for three days. She is K/C of HCV cirrhosis decompensated with ascites. On examination she has stigmata of chronic liver disease and tender abdomen. She is vitally stable and febrile.
1. What complication has this patient developed? What is the mechanism? 3. How will you diagnose this complication? 5. What is the treatment of this (immediate and long term)?
SPONTANEOUS BACTERIAL PERITONITIS (SBP) COMPLICATES ASCITES AND CAN LEAD TO RENAL DYSFUNCTION
Spontaneous Bacterial Peritonitis (SBP) Complicates Ascites and Can Lead to Renal Dysfunction
SBP
Portal Hypertension No Ascites
HVPG <10 mmHg Mild Vasodilation
Uncomplicate d Ascites
HVPG >10 mmHg Moderate Vasodilation
Refractory Ascites
Hepatorenal Syndrome
HVPG >10 mmHg Severe Vasodilation
HVPG >10 mmHg Extreme Vasodilation
BACTERIAL INFECTIONS ARE MORE FREQUENT IN SEVERE LIVER DISEASE
Bacterial Infections Are More Frequent in Severe Liver Disease Author Bleichner
n
Child A
Child B
Child C
149
3%
23%
48%
2589
1%
5%
17%
1140
3%
10%
27%
(1986) *
Kuo (1991)
Yoshida (1993)
* patients with GI hemorrhage
SPONTANEOUS BACTERIAL PERITONITIS (SBP) IS THE MOST COMMON INFECTION IN CIRRHOTIC PATIENTS
Spontaneous Bacterial Peritonitis (SBP) is the Most Common Infection in Cirrhotic Patients 150 125 100
# Hospitalize 75 d cirrhotic patients 50 25 0
SBP
UTI
Fernández et al., Hepatology 2002; 35:140
Pneumonia Procedure- Spontaneous related Bacteremia
TYPES OF BACTERIA ISOLATED FROM HOSPITALIZED CIRRHOTIC PATIENTS
Types of Bacteria Isolated from Hospitalized Cirrhotic Patients 100
Culture positive Gram (-) bacteria Gram (+) bacteria Both
80 60
%
40 20 0
SBP
UTI
Fernández et al., Hepatology 2002; 35:140
Pneumoni a
Overall
CLINICAL CHARACTERISTICS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Clinical Characteristics of Spontaneous Bacterial Peritonitis Fever Jaundice Abdominal pain Confusion Abdominal tenderness Hypotension No signs or symptoms 0
20
40
%
60
80
100
MORTALITY ASSOCIATED WITH SBP HAS BEEN DECREASING BY EARLY DIAGNOSIS AND TREATMENT
Mortality Associated with SBP has been Decreasing by Early Diagnosis and Treatment 100 80
% Mortality
60 40 20 0
1970’s
1980’s
Early 90’s Late 90’s
2000’s
EARLY DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Early Diagnosis of SBP • Diagnostic paracentesis: • If symptoms / signs of SBP occur • Unexplained encephalopathy and / or renal dysfunction • At any hospital admission • Diagnosis based on ascitic fluid PMN count >250/mm3 Rimola et al., J Hepatol 2000; 32:142
TREATMENT OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Treatment of Spontaneous Bacterial Peritonitis
• Recommended antibiotics for initial empiric therapy • i.v. cefotaxime , ceftrioxone, amoxicillin-
clavulanic acid • oral ofloxacin (uncomplicated SBP) • avoid aminoglycosides
• Minimum duration: 5 days • Re-evaluation if ascitic fluid PMN count has not decreased by at least 25% after 2 days of treatment Rimola et al., J Hepatol 2000; 32:142
RENAL DYSFUNCTION IS A POOR PROGNOSTIC SIGN IN SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Renal Dysfunction is a Poor Prognostic Sign in Spontaneous Bacterial Peritonitis Renal status Deaths No renal insufficiency
166
12 (7%)
Renal insufficiency
65
27 (42%)
Transient
21
1 (5%)
Stable
26
8 (31%)
Progressive
18
18 (100%)
Follo et al. Hepatology 1994; 20:1945
N
ALBUMIN DECREASES RENAL DYSFUNCTION AND SHORT-TERM MORTALITY IN SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Albumin Decreases Renal Dysfunction and Shortterm Mortality in Spontaneous Bacterial Peritonitis Antibiotics
Antibiotics +
alone (n=63) p
albumin (n=63)
Resolution of SBP
93% ns
98%
Renal dysfunction
32% <0.001
10%
27% Sort et al., N Engl J Med 1999; 341:403 <0.001
10%
Hospital mortality
SPONTANEOUS BACTERIAL PERITONITIS (SBP): USE OF INTRAVENOUS ALBUMIN
Spontaneous Bacterial Peritonitis Use of Intravenous Albumin Albumin (plus antibiotics) is indicated if: • BUN > 30 mg/dL • creatinine > 1.0 mg/dL • bilirubin > 4 mg/dL
Albumin is not indicated in patients with a predicted 100% cure and survival: • • • •
community-acquired SBP no GI hemorrhage no encephalopathy normal renal function
SURVIVAL AFTER DEVELOPMENT OF SPONTANEOUS BACTERIAL PERITONITIS (SBP)
Survival After Development of Spontaneous Bacterial Peritonitis 1.0 .8 .6
Probability of survival .4 (%) .2 0 0
3
6
12
24
Months Tito et al., Hepatology 1988; 8:27
36
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