0
PRINCIPLES OF MANAGEMENT OF ASCITES Richard Warner
<ul><li>Causes of Ascites </li></ul><ul><li>Management of ‘Simple Ascites’ </li></ul><ul><li>Management of ‘Refractory Asc...
Causes of Ascites-  Normal Peritoneum SAAG >11g/l <ul><li>Cirrhosis  </li></ul><ul><li>10 th  cause </li></ul><ul><li>of d...
Causes of Ascites-  Normal Peritoneum SAAG >11g/l <ul><li>Cirrhosis </li></ul><ul><li>Portal Hypertension  </li></ul><ul><...
Causes of Ascites-  Normal Peritoneum SAAG >11g/l <ul><li>Hepatic Congestion </li></ul><ul><li>Constrictive Pericarditis <...
Causes of Ascites- Normal Peritoneum SAAG < 11g/l <ul><li>Hypoalbuminaemia </li></ul><ul><li>NEPHROTIC SYNDROME </li></ul>...
Causes of Ascites- Diseased Peritoneum SAAG < 11g/l <ul><li>Bacterial, Fungal, TB, HIV Related Infections </li></ul>
Causes of Ascites- Diseased Peritoneum SAAG < 11g/l <ul><li>Malignant – Peritoneal, Pseudomyxoma Peritonei,  Primary Mesot...
 
 
Ascites is not just a Cosmetic Problem ! <ul><li>Median Survival 2 years from onset </li></ul><ul><li>Survival depends mai...
Management of Ascites- Guidelines <ul><li>International Ascites Club (Hepatology 2003/2004) –  supported by unconditional ...
Management <ul><li>Treat the Underlying Cause </li></ul><ul><li>Alcohol has best prognosis if abstain </li></ul><ul><li>Ch...
Treatment Options <ul><li>Bed rest </li></ul><ul><li>Diet </li></ul><ul><li>Diuretics </li></ul><ul><li>Fluid Restriction ...
Ascites- Grading <ul><li>Grade 1 – Ultrasound detected </li></ul><ul><li>Grade 2 moderate – symmetrical distension of abdo...
Management of ascites- Bed Rest <ul><li>Bed rest : No clinical trials </li></ul><ul><li>Upright posture activates sodium r...
Management of ascites- Sodium Restriction <ul><li>Sodium restriction : </li></ul><ul><li>Water will follow Sodium </li></u...
MANAGEMENT OF ASCITES-  Salt restriction (cont)  <ul><li>One controlled study, showed slightly reduced salt diet (120mmol/...
MANAGEMENT OF ASCITES-   WATER RESTRICTION <ul><li>Central hypovolaemia - >  stimulates ADH receptors </li></ul><ul><li>- ...
MANAGEMENT OF ASCITES- DIURETICS <ul><li>Antimineralocorticoids –  </li></ul><ul><li>Secondary hyperaldosteronism promotes...
ASCITES- Assess response to diuretics : <ul><li>Weight loss of 0.5kg/day in absence of oedema and 1kg/day when oedema pres...
Ascites- Paracentesis <ul><li>Repeated daily paracentesis ( 5L/day ) </li></ul><ul><li>Single total paracentesis- reduced ...
Ascites- Paracentesis <ul><li>5 randomised controlled trials comparing paracentesis to diuretics : more effective, shorten...
Paracentesis- Systemic Effects <ul><li>Acute increase of cardiac output, lowering of systemic vascular resistance - > mode...
Paracentesis <ul><li>Volume expander : albumin vs. synthetic expanders. </li></ul><ul><li>Albumin – expensive, risk of inf...
Ascites- Refractory Ascites <ul><li>Unresponsive to Salt restriction & high dose diuretics (400mg Spironolactone & 160mg F...
Refractory Ascites- Treatment Options <ul><li>Serial Paracentesis </li></ul><ul><li>Liver Transplantation </li></ul><ul><l...
Refractory Ascites- Treatment Options <ul><li>Serial Paracentesis </li></ul><ul><li>Safe </li></ul><ul><li>Gives insight i...
Refractory Ascites- Treatment Options <ul><li>Liver Transplantation </li></ul><ul><li>Once refractory 50% mortality @ 6/12...
 
 
Refractory Ascites- Treatment Options <ul><li>Peritoneovenous Shunts </li></ul><ul><li>Popular in 1970s </li></ul><ul><li>...
Refractory Ascites- Treatment Options <ul><li>TIPSS </li></ul>
TIPSS <ul><li>Shunt between hepatic vein (low pressure) and portal vein (high pressure) </li></ul><ul><li>Improvement of r...
 
TIPS vs. Paracentesis 58% vs.48 % 69% vs. 52% 61% vs.18% p=.006 60 Rossle et al NEJM, 2000 55% vs. 46% 71% vs. 35% 74% vs....
TIPS- Complications <ul><li>Capsule rupture </li></ul><ul><li>Intra- abdominal bleeding </li></ul><ul><li>70% shunt stenos...
ASCITES MX <ul><li>GRADE 1: no specific treatment, adv re: reduced salt intake </li></ul><ul><li>Grade 2 : dietary sodium ...
Any Questions?
TIPS VS PARACENTESIS <ul><li>3) 49 % of patients with TIPS- recurrent ascites </li></ul><ul><li>83 % with paracentesis –re...
TIPS VS PARACENTEISIS <ul><li>1) those with Child C, overall survival worse with TIPS. Therefore contraindicated (Lebreo D...
Upcoming SlideShare
Loading in...5
×

Principles Of Management Of Ascites Combined

8,499

Published on

Published in: Health & Medicine
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
8,499
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
448
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

Transcript of "Principles Of Management Of Ascites Combined"

  1. 1. PRINCIPLES OF MANAGEMENT OF ASCITES Richard Warner
  2. 2. <ul><li>Causes of Ascites </li></ul><ul><li>Management of ‘Simple Ascites’ </li></ul><ul><li>Management of ‘Refractory Ascites’ </li></ul>
  3. 3. Causes of Ascites- Normal Peritoneum SAAG >11g/l <ul><li>Cirrhosis </li></ul><ul><li>10 th cause </li></ul><ul><li>of death in </li></ul><ul><li>USA </li></ul>
  4. 4. Causes of Ascites- Normal Peritoneum SAAG >11g/l <ul><li>Cirrhosis </li></ul><ul><li>Portal Hypertension </li></ul><ul><li>Budd Chiari Syndrome </li></ul><ul><li>Fulminant Hepatic Failure </li></ul><ul><li>Massive Hepatic Metastases </li></ul><ul><li>Accounts for ~85% Ascites </li></ul>
  5. 5. Causes of Ascites- Normal Peritoneum SAAG >11g/l <ul><li>Hepatic Congestion </li></ul><ul><li>Constrictive Pericarditis </li></ul><ul><li>Congestive Heart Failure </li></ul><ul><li>Tricuspid Insufficiency </li></ul>
  6. 6. Causes of Ascites- Normal Peritoneum SAAG < 11g/l <ul><li>Hypoalbuminaemia </li></ul><ul><li>NEPHROTIC SYNDROME </li></ul><ul><li>PROTEIN LOSING ENTEROPATHY </li></ul><ul><li>SEVERE MALNUTRITION </li></ul><ul><li>Miscellaneous </li></ul><ul><li>CHYLOUS ASCITES </li></ul><ul><li>PANCREATITIS ASCITES </li></ul>
  7. 7. Causes of Ascites- Diseased Peritoneum SAAG < 11g/l <ul><li>Bacterial, Fungal, TB, HIV Related Infections </li></ul>
  8. 8. Causes of Ascites- Diseased Peritoneum SAAG < 11g/l <ul><li>Malignant – Peritoneal, Pseudomyxoma Peritonei, Primary Mesothelioma, Hepatocellular Carcinoma </li></ul><ul><li>Rare – Familial Mediterranean Fever, Vasculitis , Eosinophilic Peritonitis, Granulomatous Peritonitis </li></ul>
  9. 11. Ascites is not just a Cosmetic Problem ! <ul><li>Median Survival 2 years from onset </li></ul><ul><li>Survival depends mainly on Liver Function </li></ul><ul><li>SBP occurs ~25% </li></ul><ul><li>Low urinary Na + & SBP predict high mortality </li></ul>
  10. 12. Management of Ascites- Guidelines <ul><li>International Ascites Club (Hepatology 2003/2004) – supported by unconditional educational grant from Seale, Spain </li></ul><ul><li>American Association for the Study of Liver Disease (AASLD) – Hepatology March 2004. </li></ul><ul><li>50 % of patients diagnosed with cirrhosis, develop ascites in 10 years. </li></ul>
  11. 13. Management <ul><li>Treat the Underlying Cause </li></ul><ul><li>Alcohol has best prognosis if abstain </li></ul><ul><li>Childs C – 75% 3-year survival Vs. 0% </li></ul><ul><li>Non-Alcoholic less reversible therefore consider referral for transplant earlier </li></ul>
  12. 14. Treatment Options <ul><li>Bed rest </li></ul><ul><li>Diet </li></ul><ul><li>Diuretics </li></ul><ul><li>Fluid Restriction </li></ul><ul><li>Paracentesis </li></ul><ul><li>TIPSS </li></ul><ul><li>Shunts </li></ul><ul><li>Transplant </li></ul>
  13. 15. Ascites- Grading <ul><li>Grade 1 – Ultrasound detected </li></ul><ul><li>Grade 2 moderate – symmetrical distension of abdomen </li></ul><ul><li>Grade 3 – tense or gross ascites </li></ul><ul><li>(Refractory ascites (5 –10% of all ascites)) </li></ul>
  14. 16. Management of ascites- Bed Rest <ul><li>Bed rest : No clinical trials </li></ul><ul><li>Upright posture activates sodium retaining mechanisms , impairs renal perfusion and sodium excretion. </li></ul>
  15. 17. Management of ascites- Sodium Restriction <ul><li>Sodium restriction : </li></ul><ul><li>Water will follow Sodium </li></ul><ul><li>Educate the Patient </li></ul><ul><li>Aim for 2000mg (88 mmol) per day </li></ul><ul><li>Studies show severe restriction (22mmol/day) compared with less restricted is associated with longer duration of evolution of ascites, but higher incidence of diuretic induced renal impairment and hyponatraemia (Gauthier 1986 , Reynolds 1978) </li></ul>
  16. 18. MANAGEMENT OF ASCITES- Salt restriction (cont) <ul><li>One controlled study, showed slightly reduced salt diet (120mmol/day) was equally effective when compared to a low salt diet ( 50mmol/day). </li></ul><ul><li>No significant survival difference, although low salt diet (50mmol/day ) improved survival in those with previous GI bleed </li></ul>
  17. 19. MANAGEMENT OF ASCITES- WATER RESTRICTION <ul><li>Central hypovolaemia - > stimulates ADH receptors </li></ul><ul><li>- > decreases free water clearance - > dilutional hyponatraemia. </li></ul><ul><li>Therefore, treat by water restriction – no trials to assess effect of water restriction in patients with cirrhosis and dilutional hyponatraemia. Restriction may worsen central hypovolaemia. </li></ul><ul><li>Water restriction not first option, sodium restriction appropriate first line, water restrict if Na <125mmol/L </li></ul>
  18. 20. MANAGEMENT OF ASCITES- DIURETICS <ul><li>Antimineralocorticoids – </li></ul><ul><li>Secondary hyperaldosteronism promotes sodium retention in distal tubules and collecting ducts </li></ul><ul><li>Controlled and uncontrolled trials - > Spironolactone effective antimineralocorticoid </li></ul><ul><li>S.E gynaecomastia, renal impairment, hyperkalaemia </li></ul><ul><li>Other K sparing diuretics: amiloride, triamterene </li></ul><ul><li>Loop Diuretics : Frusemide – S.E : hyponatraemia, hypokalaemia, hypovolemia, renal impairment of prerenal origin </li></ul>
  19. 21. ASCITES- Assess response to diuretics : <ul><li>Weight loss of 0.5kg/day in absence of oedema and 1kg/day when oedema present </li></ul><ul><li>Use Spironolactone & Frusemide 100mg/40mg ratio </li></ul><ul><li>Medical treatment based on sodium restricted diet, diuretics – response in 90 % without renal failure in controlled trials (Bernadi 95, Gatta ’91) </li></ul>
  20. 22. Ascites- Paracentesis <ul><li>Repeated daily paracentesis ( 5L/day ) </li></ul><ul><li>Single total paracentesis- reduced hospital stay </li></ul>
  21. 23. Ascites- Paracentesis <ul><li>5 randomised controlled trials comparing paracentesis to diuretics : more effective, shortened duration of hospitalisation, fewer complications </li></ul><ul><li>Paracentesis should be followed by maintenance diuretics </li></ul><ul><li>Ascites recurred in 4/52 postparacentesis in 18 % of patients receiving diuretics vs. 93 % receiving placebo (Fernandez –Gsparrach 1997) </li></ul>
  22. 24. Paracentesis- Systemic Effects <ul><li>Acute increase of cardiac output, lowering of systemic vascular resistance - > modest reduction of blood pressure. </li></ul><ul><li>Pulmonary capillary pressure reduces 6 hours postparacentesis, right atrial pressure falls acutely sec to reduced intrathoracic pressure. </li></ul><ul><li>Hypovolemia occurs – therefore volume expanders used </li></ul><ul><li>Gines et al –randomised controlled trial of repeat paracentesis - patients received albumin or placebo </li></ul><ul><li>S.E in 30 % not receiving albumin vs. 16 % receiving albumin </li></ul><ul><li>SE were renal impairment, hyponatraemia, elevation of plasma renin and aldosterone levels </li></ul>
  23. 25. Paracentesis <ul><li>Volume expander : albumin vs. synthetic expanders. </li></ul><ul><li>Albumin – expensive, risk of infection with non- eradicated viruses and prion related infections </li></ul><ul><li>Practice guidelines committee of American association for study of liver disease have challenged use of albumin in view of this </li></ul>
  24. 26. Ascites- Refractory Ascites <ul><li>Unresponsive to Salt restriction & high dose diuretics (400mg Spironolactone & 160mg Frusemide) </li></ul><ul><li>Recurs rapidly after Paracentesis (< 4/52) </li></ul><ul><li>Diuretic induced complication – encephalopathy, renal impairment, hyponatraemia (<125mmol/L), hypo (3mmol/L) or hyperkalaemia (6mmol/L) </li></ul>
  25. 27. Refractory Ascites- Treatment Options <ul><li>Serial Paracentesis </li></ul><ul><li>Liver Transplantation </li></ul><ul><li>TIPSS </li></ul><ul><li>Peritoneovenous Shunts </li></ul>
  26. 28. Refractory Ascites- Treatment Options <ul><li>Serial Paracentesis </li></ul><ul><li>Safe </li></ul><ul><li>Gives insight into patient salt compliance </li></ul><ul><li>Ascitic Na similar to serum </li></ul><ul><li>6L Ascites(780mmol Na) = 10 days intake </li></ul><ul><li>Cost, Inconvenience & Infections are main disadvantages </li></ul>
  27. 29. Refractory Ascites- Treatment Options <ul><li>Liver Transplantation </li></ul><ul><li>Once refractory 50% mortality @ 6/12 and 75% mortality @ 1 year </li></ul><ul><li>Referral often delayed </li></ul><ul><li>? Suitability of patients? </li></ul>
  28. 32. Refractory Ascites- Treatment Options <ul><li>Peritoneovenous Shunts </li></ul><ul><li>Popular in 1970s </li></ul><ul><li>LeVeen or Denver </li></ul><ul><li>Poor long term patency </li></ul><ul><li>No Survival advantage </li></ul><ul><li>Make Transplantation difficult </li></ul><ul><li>Use now limited to palliation in rural areas </li></ul>
  29. 33. Refractory Ascites- Treatment Options <ul><li>TIPSS </li></ul>
  30. 34. TIPSS <ul><li>Shunt between hepatic vein (low pressure) and portal vein (high pressure) </li></ul><ul><li>Improvement of renal function and sodium excretion </li></ul><ul><li>Resolution of ascites </li></ul><ul><li>Effect on circulatory system : increase in cardiac output, right atrial pressure and pulmonary arterial pressure with secondary decrease of systemic vascular resistance. Increase in effective arterial blood volume </li></ul>
  31. 36. TIPS vs. Paracentesis 58% vs.48 % 69% vs. 52% 61% vs.18% p=.006 60 Rossle et al NEJM, 2000 55% vs. 46% 71% vs. 35% 74% vs.35% p=.008 57 Salerno et al Hepatology 2002 38% vs. 12% 40% vs. 37% 58% vs. 16% p<.001 109 Sanyal et al Gastroenterology 2003 60% vs. 34% 41% vs. 35% 51% vs. 17% p=.003 70 Gines et al Gastroenterology, 2002 Encephalopathy Survival 1 Year Control of Ascites No. Patients Study
  32. 37. TIPS- Complications <ul><li>Capsule rupture </li></ul><ul><li>Intra- abdominal bleeding </li></ul><ul><li>70% shunt stenosis in 6 months- recurrence of ascites </li></ul><ul><li>Encephalopathy- risk increased in those with pre-TIPS encephalopathy and age >60yrs </li></ul><ul><li>Risk of cardiac failure in those with underlying cardiac disease due to sudden increase in cardiac preload </li></ul><ul><li>Liver function deteriorates significantly post TIPS – secondary shunting of blood from liver </li></ul>
  33. 38. ASCITES MX <ul><li>GRADE 1: no specific treatment, adv re: reduced salt intake </li></ul><ul><li>Grade 2 : dietary sodium restriction (2000mg /day/ 88mmol/day) </li></ul><ul><li>Diuretics </li></ul><ul><li>Grade 3 : Paracentesis 8g of albumin with 1L of ascitic fluid drained, maintenance diuretics </li></ul><ul><li>Refractory : Repeat paracentesis, diuretics as tolerated – stop if complications or urine Na <30mmol/day. If >3 paracentesis/month, consider TIPS or liver transplant. </li></ul>
  34. 39. Any Questions?
  35. 40. TIPS VS PARACENTESIS <ul><li>3) 49 % of patients with TIPS- recurrent ascites </li></ul><ul><li>83 % with paracentesis –recurrent ascites </li></ul><ul><li>Higher risk of encephalopathy and cost in TIPS </li></ul><ul><li>no survival rate difference </li></ul><ul><li>(Gines P 2002) </li></ul><ul><li>4) North American multicentre trial with 109 pts- </li></ul><ul><li>TIPS superior in control of ascites but mean survival equal in both patients </li></ul>
  36. 41. TIPS VS PARACENTEISIS <ul><li>1) those with Child C, overall survival worse with TIPS. Therefore contraindicated (Lebreo D 1996) </li></ul><ul><li>2) 60 patients with refractory ascites – paracentesis without albumin vs. TIPS (Rossle M 2000) </li></ul><ul><li>TIPS – 15 deaths, 1 underwent liver transplantation </li></ul><ul><li>Paracentesis – 23 deaths, 2 underwent liver transplant </li></ul><ul><li>Probability of survival without transplant 69 % at 1year in TIPS, vs. 52 % in paracentesis. Frequency of encephalopathy similar </li></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×