The Management of Ascites in Cirrhosis: Report on the... : Hepatology (original) (raw)

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The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club

Moore, Kevin P. M.D.*,1; Wong, Florence2; Gines, Pere3; Bernardi, Mauro4; Ochs, Andreas5; Salerno, Francesco6; Angeli, Paolo7; Porayko, Michael8; Moreau, Richard9; Garcia-Tsao, Guadelupe10; Jimenez, Wladimiro11; Planas, Ramon12; Arroyo, Vicente3

1_Centre for Hepatology, Royal Free and University College Medical School, UCL, London, United Kingdom_

2_Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, Canada_

3_Liver Unit, Hospital Clinic, Barcelona and the University of Barcelona School of Medicine, Barcelona, Spain_

4_Department Medicina Interna, Cardioangiologia, Epatologia, Alma Mater Studiorum–Università di Bologna, Italy_

5_Department of Internal Medicine, University of Freiburg, Freiberg, Germany_

6_Department of Internal Medicine, IRCCS Policlinico, University of Milan, Milan, Italy_

7_Department of Clinical and Experimental Medicine, University of Padua, Padova, Italy_

8_Department of Liver Transplantation, Thomas Jefferson University, Philadelphia, PA_

9_INSERM U–481 et Service d'Hepatologie, Hopital Beaujon, Clichy, France_

10_Digestive Diseases Section, Yale University School of Medicine, New Haven, CT_

11_Hormal Laboratory, Hospital Clinic, Barcelona and the University of Barcelona School of Medicine, Barcelona, Spain_

12_Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain_

* Centre for Hepatology, Royal Free and University College Medical School, UCL, Rowland Hill St., London NW3 2PF, England. fax: (44) 207–433–2877; E-mail: [email protected].

Received: 31 October 2002; Accepted: 7 May 2003

Abstract

Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well–being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis.