INFO: The Management of Cirrhotic Ascites (long article) 
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 INFO: The Management of Cirrhotic Ascites (long article)


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The Management of Cirrhotic Ascites

Elaine Yeung, MD; Florence S. Wong, MD, FRCP(C)

Medscape General Medicine 4(4), 2002. ? 2002 Medscape
Posted 10/22/2002


Ascites occurs in 50% of patients within 10 years of diagnosis of
compensated cirrhosis.[1] It is a poor prognostic indicator, with a 50%
2-year survival,[2] worsening significantly to 20% to 50% at 1 year when
the ascites becomes refractory to medical therapy.[3,4] Ascites also
predisposes patients to life-threatening complications such as spontaneous
bacterial peritonitis and hepatorenal syndrome, and therefore is a major
indication for liver transplantation. Effective management of ascites
requires a thorough understanding of the pathophysiology of ascites
formation and the rationale for various treatment modalities.


The pathophysiology leading to ascites formation is complex. Subtle sodium
and water retention develops early in cirrhosis, and this becomes more avid
as the cirrhotic process progresses. The presence of cirrhosis is
associated with hemodynamic changes. Systemic and splanchnic vasodilatation
occurs due to an imbalance of vasoactive substances, favoring vasodilators.
The latter results in a decrease in effective circulating {*filter*} volume. The
perceived hypovolemia in turn activates various vasoconstrictor systems,
including the sympathetic nervous system, the renin-angiotensin-aldosterone
system, and arginine vasopressin, producing renal vasoconstriction with a
decrease in glomerular filtration rate (GFR), as well as an increase in
renal sodium and water reabsorption.[5] Independent of the hemodynamic
changes, hepatic dysfunction also enhances renal sodium retention through
some yet undefined mechanism, as sodium excretion has been shown to be
related to a threshold of hepatic function.[6,7] The presence of portal
hypertension then preferentially localizes the excess fluid to the
peritoneal cavity.

Treatment of Cirrhotic Ascites

Treating Reversible Causes of Cirrhosis

In 1997, {*filter*}ic liver disease accounted for 40% of deaths from cirrhosis
in the United States.[8] One prospective study[9] has shown reduction of
portal pressures in some patients following a period of abstinence from
{*filter*}, with possible resolution of ascites or greater responsiveness to
medical therapy. Irrespective of the etiology of cirrhosis, all patients
should be advised to abstain from {*filter*} completely, including avoidance
of {*filter*}-containing medications and so-called "non{*filter*}ic" beers.[10]

Mon, 18 Apr 2005 07:13:35 GMT
 [ 1 post ] 

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