Ascites: Diagnosis and Management

Medical Clinics of North America

Volumn 93, Issue 4, 2009, Pages 801-817

  Hou, Wei ^a   Sanyal, Arun J ^a  

^a VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

Ascites; Cirrhosis; Furosemide; Portal hypertension; Refractory ascites; Spironolactone; Spontaneous bacterial peritonitis; Transjugular intrahepatic portosystemic shunts

Indexed keywords

ALBUMIN; AMILORIDE; ANTIBIOTIC AGENT; CEPHALOSPORIN; CLONIDINE; DIURETIC AGENT; FUROSEMIDE; LOOP DIURETIC AGENT; QUINIDINE SULFATE; QUINOLONE; SPIRONOLACTONE; TAMOXIFEN;

ASCITES; ASCITES FLUID CYTOLOGY; BACTERIAL PERITONITIS; CLINICAL TRIAL; COMPUTER ASSISTED TOMOGRAPHY; DIET THERAPY; DISEASE CLASSIFICATION; DISEASE SEVERITY; DRUG DOSE INCREASE; DRUG MECHANISM; DRUG MEGADOSE; GYNECOMASTIA; HEPATIC ENCEPHALOPATHY; HUMAN; HYPERKALEMIA; HYPOKALEMIA; HYPONATREMIA; IMPOTENCE; KIDNEY DISEASE; KIDNEY FAILURE; LABORATORY TEST; LIBIDO; LIVER CIRRHOSIS; LIVER TRANSPLANTATION; MENSTRUAL IRREGULARITY; MUSCLE CRAMP; NUCLEAR MAGNETIC RESONANCE IMAGING; PARACENTESIS; PATHOPHYSIOLOGY; PERITONEUM VEIN SHUNT; PHYSICAL EXAMINATION; PRIORITY JOURNAL; REVIEW; SIDE EFFECT; SODIUM RESTRICTION; TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT; UNSPECIFIED SIDE EFFECT;

ASCITES; ASCITIC FLUID; CARDIAC OUTPUT; DIET, SODIUM-RESTRICTED; DISEASE PROGRESSION; DIURETICS; DRUG THERAPY, COMBINATION; FUROSEMIDE; HUMANS; HYPERTENSION, PORTAL; LIVER CIRRHOSIS; PARACENTESIS; PERITONEOVENOUS SHUNT; PERITONITIS; PORTASYSTEMIC SHUNT, TRANSJUGULAR INTRAHEPATIC; PROGNOSIS; SPIRONOLACTONE; SPLANCHNIC CIRCULATION; VASODILATION;

EID: 67649388059     PISSN: 00257125     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.mcna.2009.03.007     Document Type: Review

References (93)

1. Hernandez-Guerra M., Garcia-Pagan J.C., and Bosch J. Increased hepatic resistance: a new target in the pharmacologic therapy of portal hypertension. J Clin Gastroenterol 39 (2005) 131-137
2. Gines P., Cardenas A., Arroyo V., et al. Management of cirrhosis and ascites. N Engl J Med 350 (2004) 1646-1654
3. Moller S., Bendtsen F., and Henriksen J.H. Pathophysiological basis of pharmacotherapy in the hepatorenal syndrome. Scand J Gastroenterol 40 (2005) 491-500
4. Schrier R.W., Arroyo V., Bernardi M., et al. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 8 (1988) 1151-1157
5. Arroyo V., Ginès P., Gerbes A.L., et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 23 (1996) 164-176
6. Oben J.A., and Diehl A.M. Sympathetic nervous system regulation of liver repair. Anat Rec A Discov Mol Cell Evol Biol 280 (2004) 874-883
7. Arroyo V., and Gines P. Mechanism of sodium retention and ascites formation in cirrhosis. J Hepatol 17 (1993) 24-28
8. Jimenez-Saenz M., Soria I.C., Bernardez J.R., et al. Renal sodium retention in portal hypertension and hepatorenal reflex: from practice to science. Hepatology 37 (2003) 1494-1495
9. Iwakiri Y., and Groszmann R. The hyperdynamic circulation of chronic liver diseases: from the patient to the molecule. Hepatology 43 (2006) S121-S131
10. Iwakiri Y., and Groszmann R. Vascular endothelial dysfunction in cirrhosis. J Hepatol 46 (2007) 927-934
11. Wiest R., Das S., and Cadelina G. Bacterial translocation in cirrhotic rats stimulates eNOS-derived NO production and impairs mesenteric vascular contractility. J Clin Invest 104 (1999) 1223-1233
12. Wiest R., and Garcia-Tsao G. Bacterial translocation (BT) in cirrhosis. Hepatology 41 (2005) 422-433
13. Riordan S.M., and Williams R. The intestinal flora and bacterial infection in cirrhosis. J Hepatol 45 (2006) 744-757
14. Runyon B.A., Montano A.A., Akriviadis E.A., et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 117 (1992) 215-220
15. Runyon B.A. Management of adult patients with ascites due to cirrhosis. Hepatology 39 (2004) 1-16
16. Moore K.P., Wong F., and Ginès P. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 38 (2003) 258-266
17. Moore K.P., and Aithal G.P. Guidelines on the management of ascites in cirrhosis. Gut 55 Suppl 6 (2006) vi1-12
18. Runyon B.A. Care of patient with ascites. N Engl J Med 330 (1994) 337-342
19. Sakai H., Mendler M.H., and Runyon B.A. The left lower quadrant is the best site for paracentesis: an ultrasound evaluation. Hepatology 36 (2002) 525A [abstract]
20. Runyon B.A. Paracentesis of ascetic fluid: a safe procedure. Arch Intern Med 146 (1986) 2259-2261
21. Webster S.T., Brown K.L., Lucey M.R., et al. Hemorrhagic complications of large volume abdominal paracentesis. Am J Gastroenterol 92 (1996) 366-368
22. Caly W.R., and Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol 18 (1993) 353-358
23. Bac D.-J., Siersema P.D., Mulder P.G.H., et al. Spontaneous bacterial peritonitis: outcome and predictive factors. Eur J Gastroenterol Hepatol 5 (1993) 635-640
24. Rimola A., Garcia-Tsao G., Navasa M., et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol 32 (2000) 142-153
25. Pinzello G., Simonetti R.G., Craxi A., et al. Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic patients. Hepatology 3 (1983) 545-549
26. Ginès P., and Cárdenas A. The management of ascites and hyponatremia in cirrhosis. Semin Liver Dis 28 (2008) 43-58
27. Hooefs J.C. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 102 (1983) 260-273
28. Ghassemi S., and Garcia-Tsao G. Prevention and treatment of infections in patients with cirrhosis. Best Pract Res Clin Gastroenterol 21 (2007) 77-93
29. Castellote J., Lopez C., Gornals J., et al. Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strip. Hepatology 37 (2003) 893-896
30. Runyon B.A. Strips and tubes: refining the diagnosis of spontaneous bacterial peritonitis. Hepatology 37 (2003) 745-747
31. Runyon B.A., Canwati H.N., and Akriviadis E.A. Optimization of ascetic fluid culture technique. Gastroenterology 95 (1988) 1351-1355
32. Runyon B.A., Antillon M.R., Akriviadis E.A., et al. Bedside inoculation of blood culture bottles is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J Clin Microbiol 28 (1990) 2811-2812
33. Castellote J., Xiol X., Verdaguer R., et al. Comparison of two ascetic fluid culture methods in cirrhotic patients with spontaneous bacterial peritonitis. Am J Gastroenterol 85 (1990) 1605-1608
34. Akriviadis E.A., and Runyon B.A. The value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 98 (1990) 127-133
35. Wu S.S., Lin O.S., Chen Y.-Y., et al. Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. J Hepatol 34 (2001) 215-221
36. Runyon B.A. Amylase levels in ascetic fluid. J Clin Gastroenterol 9 (1987) 172-174
37. Polak M., and Mattosinho Francis L.C. Chronic pancreatitis with massive ascites. Digestion 1 (1968) 296-304
38. Schindler S.C., Schaefer J.W., Hull D., et al. Chronic pancreatic ascites. Gastroenterology 59 (1970) 453-459
39. DeSitter L., and Rector Jr. W.G. The significance of bloody ascites in patients with cirrhosis. Am J Gastroenterol 95 (1984) 1351-1355
40. Molina R., Filella X., Bruix J., et al. Cancer antigen 125 in serum and ascitic fluid of patients with liver diseases. Clin Chem 37 (1991) 1379-1383
41. Zuckerman E., Lanir A., Sabo E., et al. Cancer antigen 125: a sensitive marker of ascites in patients with liver cirrhosis. Am J Gastroenterol 94 (1999) 1613-1618
42. Sari R., Yildirim B., Sevinc A., et al. Sensitity of cancer antigen 125 in patients with liver cirrhosis in the presence of ascites. [Erratum in Am J Gastroenterol 2001; 96: 1319]. Am J Gastroenterol 96 (2001) 253-254
43. Runyon B.A., Hoefs J.C., and Morgan T.R. Ascitic fluid analysis in malignancy-related ascites. Hepatology 8 (1988) 1104-1109
44. Hillebrand D.J., Runyon B.A., Yasmineh W.G., et al. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 24 140 (1996) 1408-1412
45. Cappell M.S., and Shetty V. A multicenter, case-controlled study of the clinical presentation and etiology of ascites and of the safety and efficacy of diagnostic abdominal paracentesis in HIV seropositive patients. Am J Gastroenterol 89 (1994) 2172-2177
46. Gines P., Fernandez-Esparrach G., Arroyo V., et al. Pathogenesis of ascites in cirrhosis. Semin Liver Dis 17 (1997) 175-189
47. Ring-Larsen H., Henriksen J.H., Wilken C., et al. Diuretic treatment in decompensated cirrhosis and congestive heart failure: effect of posture. BMJ 292 (1986) 1351-1353
48. Salo J., Gines A., Anibarro L., et al. Effect of upright posture and physical exercise on endogenous neurohumoral systems in cirrhotic patients with sodium retention and normal supine plasma renin, aldosterone, and norepinephrine levels. Hepatology 22 (1995) 479-487
49. Salo J., Guevara M., Fernandez-Esparrach G., et al. Impairment of renal function during moderate physical exercise in cirrhotic patients with ascites: relationship with the activity of neurohormonal systems. Hepatology 25 (1997) 1338-1342
50. Eisenmenger W.J., Ahrens E.H., Blondheim S.H., et al. The effect of rigid sodium restriction in patients with cirrhosis of the liver and ascites. J Lab Clin Med 34 (1949) 1029-1038
51. Stiehm A.J., Mendler M.H., and Runyon B.A. Detection of diuretic-resistance or diuretic-sensitivity by the spot urine Na/K ratio in 729 specimens from cirrhotics with ascites: approximately 90% accuracy as compared to 24-hr urine Na excretion. Hepatology 36 (2002) 222A [abstract]
52. Descos L., Gauthier A., Levy V.G., et al. Comparison of six treatments of ascites in patients with liver cirrhosis. Hepatogastroenterology 30 (1983) 15-20
53. Gauthier A., Levy V.G., Quinton A., et al. Salt or no salt in the treatment of cirrhotic ascites: a randomised study. Gut 27 (1986) 705-709
54. Gerbes A.L. Medical treatment of ascites in cirrhosis. J Hepatol 17 (1993) S4-S9
55. Runyon B.A. Ascites and spontaneous bacterial peritonitis. In: Feldman M., Friedman L.S., and Sleisenger M.H. (Eds). Sleisenger and Fordtran's gastrointestinal and liver disease. 7th edition (2002), Saunders, Philadelphia 1517-1542
56. Veldt B.J., Laine F., Guillogomarc'h A., et al. Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing. J Hepatol 36 (2002) 93-98
57. Aqel B.A., Scolapio J.S., Dickson R.C., et al. Contribution of ascites to impaired gastric function and nutritional intake in patients with cirrhosis and ascites. Clin Gastroenterol Hepatol 3 (2005) 1095-1100
58. Henkel A.S., and Buchman A.L. Nutritional support in patients with chronic liver disease. Nat Clin Pract Gastroenterol Hepatol 3 (2006) 202-209
59. McCullough A.J. Nutrition and malnutrition in liver disease. In: Wolfe M.M., Davis G.L., Farraye F., et al. (Eds). Therapy of digestive disorders. 2nd edition (2006), Saunders, Philadelphia 67-83
60. Kearns P.J., Young H., and Garcia G. Accelerated improvement of alcoholic liver disease with enteral nutrition. Gastroenterology 102 (1992) 200-205
61. Cabrè E., Gonzalez-Hux F., and Abad-Lacruz A. Effect of total enteral nutrition on the short-term outcome of severely malnourished cirrhotics: a randomized controlled trial. Gastroenterology 98 (1990) 715-720
62. Perez-Ayuso R.M., Arroyo V., Planas R., et al. Randomized comparative study of efficacy of furosemide vs. spironolactone in nonazotemic cirrhosis with ascites. Gastroenterology 84 (1983) 961-968
63. Sungaila I., Bartle W.R., Walker S.E., et al. Spironolactone pharmacokinetics and pharmacodynamics in patients with cirrhotic ascites. Gastroenterology 102 (1992) 1680-1685
64. Daskalopoulos G., Laffi G., Morgan T., et al. Immediate effects of furosemide on renal hemodynamics in chronic liver disease with ascites. Gastroenterology 92 (1987) 1859-1863
65. Angeli P., Pria M.D., De Bei E., et al. Randomized clinical study of the efficacy of amiloride and potassium canrenoate in nonazotemic cirrhotic patients with ascites. Hepatology 19 (1994) 72-79
66. Karim A. Spironolactone metabolism in man revisited. In: Brunner H.R. (Ed). Contemporary trends in diuretic therapy (1986), Excerpta Medica, Amsterdam 22-37
67. Pockros P.J., and Reynolds T.B. Rapid diuresis in patients with ascites from chronic liver disease: the importance of peripheral edema. Gastroenterology 90 (1986) 1827-1833
68. Stanley M.M., Ochi S., Lee K.K., et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. N Engl J Med 321 (1989) 1632-1638
69. Gines P., Arroyo V., Quintero E., et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites: results of a randomized study. Gastroenterology 93 (1987) 234-241
70. Moreau R., Lec S.S., Hadengue A., et al. Hemodynamic effects of a clonidine-induced decrease in sympathetic tone in patients with cirrhosis. Hepatology 7 (1987) 149-154
71. Esler M., Dudley F., Jennings G., et al. Increased sympathetic nervous activity and the effects of its inhibition with clonidine in alcoholic cirrhosis. Ann Intern Med 116 (1992) 446-455
72. Roulot D., Moreau R., Gaudin C., et al. Long term sympathetic and hemodynamic responses to clonidine in patients with cirrhosis. Gastroenterology 102 (1992) 1309-1318
73. Lenaerts A., Van Cauter J., Moukhaiber H., et al. Treatment of refractory ascites with clonidine and spironolactone. Gastroenterol Clin Biol 21 (1997) 524-525
74. Lenaerts A., Codden T., Van Cauter J., et al. Interest of the association clonidine-spironolactone in cirrhotic patients with ascites and activation of sympathetic nervous system. Acta Gastroenterol Belg 65 (2002) 1-5
75. Lenaerts A., Codden T., Meunier J.D., et al. Effects of clonidine on diuretic response in ascitic patients with cirrhosis and activation of sympathetic nervous system. Hepatology 44 (2006) 844-849
76. Lee F.Y., Lee S.D., Hwang S.J., et al. A randomized controlled trial of quinidine in the treatment of cirrhotic patients with muscle cramps. J Hepatol 12 (1991) 236-240
77. Angeli P., Albino G., Carraro P., et al. Cirrhosis and muscle cramps: evidence of a causal relationship. Hepatology 23 (1996) 264-273
78. Peltekian K.M., Wong F., Liu P.P., et al. Cardiovascular, renal and neurohumoral responses to single large-volume paracentesis in cirrhotic patients with diuretic-resistant ascites. Am J Gastroenterol 92 (1997) 394-399
79. Runyon B.A. Patient selection is important in studying the impact of large-volume paracentesis on intravascular volume. Am J Gastroenterol 92 (1997) 371-373
80. Tito L., Gines P., Arroyo V., et al. Total paracentesis associated with intravenous albumin management of patients with cirrhosis and ascites. Gastroenterology 98 (1990) 146-151
81. Quintero E., Gines P., Arroyo V., et al. Paracentesis versus diuretics in the treatment of cirrhotics with tense ascites. Lancet 16 (1985) 611-612
82. Ruiz-Del-Arbol L., Monescillo A., Jimenez W., et al. Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology 113 (1997) 579-586
83. Gines P., Tito L., Arroyo V., et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 94 (1988) 1493-1502
84. Gines A., Fernandez-Esparrach G., Monescillo A., et al. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 111 (1996) 1002-1010
85. Wong F., Sniderman K., Liu P., et al. The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt. Gastroenterology 112 (1997) 899-907
86. Sanyal A.J., Genning C., Reddy K.R., et al. The North American Study for the Treatment of Refractory Ascites. Gastroenterology 124 (2003) 634-641
87. Malinchoc M., Kamath P.S., Gordon F.D., et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31 (2000) 864-871
88. Albillos A., Banares R., Gonzalez M., et al. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol 43 (2005) 990-996
89. Londono M.C., Guevara M., Rimola A., et al. Hyponatremia impairs early posttransplantation outcome in patients with cirrhosis undergoing liver transplantation. Gastroenterology 130 (2006) 1135-1143
90. Garcia-Tsao G. Bacterial infections in cirrhosis. Can J Gastroenterol 18 (2004) 405-406
91. Runyon B.A., McHutchison J.G., Antillon M.R., et al. Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology 100 (1991) 1737-1742
92. Tito L., Rimola A., Gines P., et al. Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors. Hepatology 8 (1988) 27-31
93. Fernandez J., Navasa M., Planas R., et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology 133 (2007) 818-824