Ascites in adults with cirrhosis: Initial therapy
- José Such, MD, PhD
José Such, MD, PhD
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, UAE
- Clinical Professor, Lerner School of Medicine. Case Western Reserve University, OH, US
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Cirrhosis is the most common cause of ascites in the United States, accounting for approximately 85 percent of cases . In addition, ascites is the most common complication of cirrhosis. Within 10 years after the diagnosis of compensated cirrhosis, approximately 58 percent of patients will have developed ascites . (See "Pathogenesis of ascites in patients with cirrhosis".)
Successful treatment of the patient with ascites depends upon an accurate diagnosis regarding the cause of ascites formation [3,4]. A careful history, physical examination, and abdominal paracentesis with appropriate ascitic fluid analysis can usually determine the cause of ascites formation [1,3]. Patients who have a cause for ascites formation other than cirrhosis may not respond to the treatments used in those with cirrhosis. This is particularly true for ascites due to peritoneal carcinomatosis, in which sodium restriction and diuretics cause intravascular volume depletion without mobilization of the ascitic fluid . (See "Evaluation of adults with ascites" and 'Diuretic therapy' below and "Malignancy-related ascites".)
This topic will review the initial therapy of ascites in patients with cirrhosis. The diagnosis and evaluation of patients with ascites, the treatment of refractory ascites, and the management of spontaneous bacterial peritonitis are discussed elsewhere. (See "Evaluation of adults with ascites" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites" and "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis".)
The management of ascites in adults with cirrhosis is also discussed in a 2013 guideline from the American Association for the Study of Liver Diseases (table 1) [6,7]. The discussion that follows is consistent with that guideline.
GOALS OF THERAPY
The goals of therapy in patients with ascites are to minimize ascitic fluid volume and decrease peripheral edema, without causing intravascular volume depletion. Although there is no evidence that treatment of fluid overload in patients with cirrhosis improves survival, the following benefits have been noted:
- Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
- Ginés P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987; 7:122.
- Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009; 49:2087.
- European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53:397.
- Pockros PJ, Esrason KT, Nguyen C, et al. Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Gastroenterology 1992; 103:1302.
- Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 2013; 57:1651.
- http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf (Accessed on April 23, 2013).
- Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology 1986; 6:396.
- Runyon BA, Antillon MR, McHutchison JG. Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis. J Hepatol 1992; 14:249.
- Dolz C, Raurich JM, Ibáñez J, et al. Ascites increases the resting energy expenditure in liver cirrhosis. Gastroenterology 1991; 100:738.
- Said A, Williams J, Holden J, et al. The prevalence of alcohol-induced liver disease and hepatitis C and their interaction in a tertiary care setting. Clin Gastroenterol Hepatol 2004; 2:928.
- Powell WJ Jr, Klatskin G. Duration of survival in patients with Laennec's cirrhosis. Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. Am J Med 1968; 44:406.
- Veldt BJ, Lainé F, Guillygomarc'h A, et al. Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing. J Hepatol 2002; 36:93.
- REYNOLDS TB, GELLER HM, KUZMA OT, REDEKER AG. Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med 1960; 263:734.
- Runyon BA. Historical aspects of treatment of patients with cirrhosis and ascites. Semin Liver Dis 1997; 17:163.
- Addolorato G, Leggio L, Ferrulli A, et al. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet 2007; 370:1915.
- Addolorato G, Caputo F, Capristo E, et al. Baclofen efficacy in reducing alcohol craving and intake: a preliminary double-blind randomized controlled study. Alcohol Alcohol 2002; 37:504.
- Garbutt JC, Kampov-Polevoy AB, Gallop R, et al. Efficacy and safety of baclofen for alcohol dependence: a randomized, double-blind, placebo-controlled trial. Alcohol Clin Exp Res 2010; 34:1849.
- Yamini D, Lee SH, Avanesyan A, et al. Utilization of baclofen in maintenance of alcohol abstinence in patients with alcohol dependence and alcoholic hepatitis with or without cirrhosis. Alcohol Alcohol 2014; 49:453.
- Heydtmann M, Macdonald B, Lewsey J, et al. The GABA-B agonist baclofen improves alcohol consumption, psychometrics and may have an effect on the hospital admission rates of patients with alcoholic liver disease. Hepatology 2012; 56:1091A.
- Malekzadeh R, Mohamadnejad M, Rakhshani N, et al. Reversibility of cirrhosis in chronic hepatitis B. Clin Gastroenterol Hepatol 2004; 2:344.
- Llach J, Ginès P, Arroyo V, 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. Gastroenterology 1988; 94:482.
- Sersté T, Melot C, Francoz C, et al. Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites. Hepatology 2010; 52:1017.
- Boyer TD, Zia P, Reynolds TB. Effect of indomethacin and prostaglandin A1 on renal function and plasma renin activity in alcoholic liver disease. Gastroenterology 1979; 77:215.
- Arroyo V, Ginés P, Rimola A, Gaya J. Renal function abnormalities, prostaglandins, and effects of nonsteroidal anti-inflammatory drugs in cirrhosis with ascites. An overview with emphasis on pathogenesis. Am J Med 1986; 81:104.
- de Lédinghen V, Mannant PR, Foucher J, et al. Non-steroidal anti-inflammatory drugs and variceal bleeding: a case-control study. J Hepatol 1996; 24:570.
- García-Pagán JC, Salmerón JM, Feu F, et al. Effects of low-sodium diet and spironolactone on portal pressure in patients with compensated cirrhosis. Hepatology 1994; 19:1095.
- Wensing G, Lotterer E, Link I, et al. Urinary sodium balance in patients with cirrhosis: relationship to quantitative parameters of liver function. Hepatology 1997; 26:1149.
- Arroyo V, Bosch J, Gaya-Beltrán J, et al. Plasma renin activity and urinary sodium excretion as prognostic indicators in nonazotemic cirrhosis with ascites. Ann Intern Med 1981; 94:198.
- Angeli P, Wong F, Watson H, et al. Hyponatremia in cirrhosis: Results of a patient population survey. Hepatology 2006; 44:1535.
- Fogel MR, Sawhney VK, Neal EA, et al. Diuresis in the ascitic patient: a randomized controlled trial of three regimens. J Clin Gastroenterol 1981; 3 Suppl 1:73.
- Sawhney VK, Gregory PB, Swezey SE, Blaschke TF. Furosemide disposition in cirrhotic patients. Gastroenterology 1981; 81:1012.
- Daskalopoulos G, Laffi G, Morgan T, et al. Immediate effects of furosemide on renal hemodynamics in chronic liver disease with ascites. Gastroenterology 1987; 92:1859.
- Spahr L, Villeneuve JP, Tran HK, Pomier-Layrargues G. Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites. Hepatology 2001; 33:28.
- Angeli P, Fasolato S, Mazza E, et al. Combined versus sequential diuretic treatment of ascites in non-azotaemic patients with cirrhosis: results of an open randomised clinical trial. Gut 2010; 59:98.
- Therapie innerer Krankheiten, 9th ed, Paumgartner G, Brandt T, Greten H, et al. (Eds), Springer-Verlag, Berlin 2013.
- Artz SA, Paes IC, Faloon WW. Hypokalemia-induced hepatic coma in cirrhosis. Occurrence despite neomycin therapy. Gastroenterology 1966; 51:1046.
- Pérez-Ayuso RM, Arroyo V, Planas R, et al. Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites. Relationship between the diuretic response and the activity of the renin-aldosterone system. Gastroenterology 1983; 84:961.
- Pinzani M, Daskalopoulos G, Laffi G, et al. Altered furosemide pharmacokinetics in chronic alcoholic liver disease with ascites contributes to diuretic resistance. Gastroenterology 1987; 92:294.
- Angeli P, Dalla Pria M, De Bei E, et al. Randomized clinical study of the efficacy of amiloride and potassium canrenoate in nonazotemic cirrhotic patients with ascites. Hepatology 1994; 19:72.
- Dimitriadis G, Papadopoulos V, Mimidis K. Eplerenone reverses spironolactone-induced painful gynaecomastia in cirrhotics. Hepatol Int 2011; 5:738.
- Pockros PJ, Reynolds TB. Rapid diuresis in patients with ascites from chronic liver disease: the importance of peripheral edema. Gastroenterology 1986; 90:1827.
- Boyer TD. Removal of ascites: what's the rush? Gastroenterology 1986; 90:2022.
- Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 2010; 303:1716.
- Runyon BA. Treatment of patients with cirrhosis and ascites. Semin Liver Dis 1997; 17:249.
- Stanley MM, Ochi S, Lee KK, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites. N Engl J Med 1989; 321:1632.
- Peltekian KM, Wong F, Liu PP, et al. Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites. Am J Gastroenterol 1997; 92:394.
- Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 2012; 55:1172.
- GOALS OF THERAPY
- THRESHOLD FOR INITIATING TREATMENT
- THERAPEUTIC APPROACH
- Management of underlying liver disease
- - Alcohol abstinence
- - Management of other liver diseases
- Medications to avoid or use with caution
- - Avoidance of angiotensin inhibition
- - Propranolol
- - Avoidance of NSAIDs
- Dietary sodium restriction
- Fluid restriction
- Diuretic therapy
- - Diuretic regimen
- - Rate of fluid removal
- - Patient monitoring
- - Diuretic resistance
- Large-volume paracentesis
- Liver transplantation and shunts
- MANAGEMENT OF COMPLICATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS