Management And Complications Of Ascites Srava.pptx

Management and complications of Ascites - Shravan ( R3 )

FACTS :

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60 % of cirrhotic pts will develop ASCITES , by end of 10 yrs Portal hypertension > 12 mmHg Ideally Ascitic tapping should be done in all patients suspected to have SBP

Grading of ASCITES GRADE

SEVERITY

CLINICAL

USG

TREATMENT

1

MILD

--

+

Sodium restriction

++

Sodium restriction Diuretics

2

3

MODERATE

SEVERE

+

++

+++

Paracentesis Sodium restriction Diuretics

MINIMUM AMOUNT OF FLUID REQUIRED TEST

MINIMUM FLUID IN (ml.)

Puddle Sign

120

Shifting Dullness

500

Fluid Thrill

1000- 1500

USG

100

CT Scan

50

Treatment of Ascites 

Fluid restriction

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Salt restriction

( mild < 2 gm/day , moderate : < 1gm/day ) 

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Diuretics

( maintain ratio : 100 : 40 )

Therapeutic Ascitic tapping ( LVP + albumin )

1) To start with aldosterone antagonist ( mono drug) , later can add furosemide ( 2 drug ) 2) weight loss : 0.5 kg/day in patients without edema 1 kg/day in patients with edema 3) All diuretics should be discontinued if there is severe hyponatremia ( Na+ <120mmol/L), progressive renal failure, worsening hepatic encephalopathy or incapacitating muscle cramps . 4) Furosemide should be stopped if there is severe hypokalemia (<3 mmol/L). Aldactone should be stopped if there is severe hyperkalemia ( >6 mmol/L). 5) LVP + Albumin ( 8gm/l of ascitic fluid removed)

Complications 

Refractory ascites

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SBP ( spontaneous bacterial peritonitis )

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Hepatic encephalopathy - Grading

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HRS ( hepato renal syndrome ) - 2 types

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HPS ( hepato pulmonary syndrome ) - TRIAD

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Porto – Pulmonary HTN

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Hepatic hydrothorax

Refractory ascites

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First line Rx : LVP + Albumin ( 8gm/l )

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Second line Rx : TIPS

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Other shunts :

1) Peritoneo-venous ( le-veen , denver ) 2)Porto – Systemic shunt 

LIVER TRANSPLANT

TIPSS 

Merit : less recurrence

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De-merit : slow , needs diuretics ,

precipitates HE 

Contra indicated : Bil > 5 , INR >2 , Child Pugh > 11 , MELD > 23

sepsis , HE 2 , ARF ,

Studies on TIPS vs LVP

SBP ( spontaneous bacterial peritonitis ) 

Neutrophil count > 250 (+/- positive culture )

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Bacter-ascites : Neutrophic < 250 , culture +

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If fever ---> treat as SBP

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If no fever --> repeat paracentensis ---> SBP +/-

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NEED TO R/O SECONDARY BACTERIAL PERITONITIS

Treatment of SBP 

First choice : 3rd gen cephalosporins

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Second choice : augmentin , Fqs

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Treatment response : repeat tapping > 48 hrs

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Give ALBUMIN ( 1st : 1.5 gm/kg -> 2nd : 1 gm/kg)

CLINICAL TRIALS

Prophylaxis for SBP 

Secondary : Norflox 400mg od daily /

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Ciproflox 750mg weekly once

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Bactrim DS od daily

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Primary : severe dis : ceftriaxone non severe dis : FQ, Bactrim DS

HRS ( hepato renal syndrome ) 

TYPES OF HRS HRS

COURSE

CREAT

TRIGGERED

TYPE 1 ( dangerous )

RAPID < 2 weeks

 >2.5mg/dl ,  GFR < 20 ml/min

SEPSIS ( SBP) UGI Bleed Acute hepatitis Over diuresis LVP Cholestasis

TYPE 2 ( benign )

SLOW upto 6 months

 > 1.5mg/dl  GFR <40 ml/min

--

Others

Diuretic resistance and Refractory ascites

Pathophysiology 

Splanchnic vasodilataion

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RAS – increased activity

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Sympathetic activity

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Cirrhotic cardiomyopathy

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Vasomediators – NO , TxA2 , Endothelin1, LK

Treatment of HRS 

First choice : Terlipressin ( 1mg/ 4-6 hrly) + albumin

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Nor epinephrine + albumin

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Midodrine + octreotide + albumin

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TIPSS

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Renal transplant

PROPHYLAXIS FOR HRS : • All SBP pts should recieve albumin • Severe alcoholic hepatitis pts to be given pentoxyphylline • Antibiotics – Norfloxacin

Differential diagnosis : PRE RENAL

ATN

HRS

CKD

Urine Na+

<10

>20

<10

>30

Proteinuria

nil

< 500

< 500

>500

Ur cr/ plasma cr

>20

<15

>30

< 20

Precipitants

Decreased effective arterial Volume

Decreased effective arterial Volume

CLD, SBP , UGI bleed , Refractory ascites

Renal disease

Volume expansion

Immediately improved

Maintain euvolemic status

NOT IMPROVED Maintain euvolemic status

• References : 1) EASL guidelines 2) Up to date 3) Harrison

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