Factors Influencing Ascites in Patients With Cirrhosis of the Liver 1

Abstract

The level of serum ablumin has been said to be the controlling factor in the accumulation of ascitic fluid in patients with cirrhosis of the liver (1 to 4). Several investigators have reported an increased portal pressure in patients with the disease (5 to 7) and this has been conceded to contribute to the development of ascites. During the past 3 years, we have observed patients with cirrhosis of the liver who have accumulated ascitic fluid in such quantities that repeated paracenteses were required. The plasma levels of albumin and globulin were determined at regular intervals. The patients received, in addition to an adequate diet, an aqueous extract of liver prepared at the Rockefeller Institute for Medical Research. The liver extract, diluted with saline, was administered intravenously. As a result of the combined therapy, the reaccumulation of ascitic fluid was arrested after varying periods of time in the different patients and further paracenteses were unnecessary. We were thus able to compare the plasma levels of albumin and globulin during and after the period of fluid retention. In addition, determinations of plasma proteins were made on a group of patients with severe cirrhosis of the liver in whom ascites had never been present.This report is concerned with these observations. As the results did not indicate that the level of albumin in the plasma was the determining factor in the fluid retention, data are presented to support another theory in explanation of this disturbance. STUDIES ON PATIENTSThe patients selected for this study were those in whom severe liver damage was unquestionably present 1 This research was aided by grants from the Milbank Memorial Foundation and from the Nutrition Foundation.as evidenced by the physical findings and laboratory tests. A history of chronic alcoholism extending over a period of years was given by each patient. During the period of hospitalization, the patients were on the wards of the 3rd (New York University) Medical Division of Bellevue Hospital. When discharged, they were seen regularly in the Meta5olism Clinic of New York University College of Medicine. The diet consisted of 450 grams of carbohydrate, 100 to 120 grams of protein, and 85 grams of fat. Meat was given only once a day and the rest of the protein was derived from milk, eggs, cheese, and gelatine.2 The liver extract8 was given intravenously in doses of 5 to 10 ml. diluted with 40 ml. of N/saline. Two to 3 injections were given weekly. The plasma levels of albumin and globulin were determined by the method of Howe (8). The total proteins were done by the micro Kjeldahl method. Plasma cholesterols were determined by a modification of the Schoenheimer and Sperry method (9)-, and were read in the photoelectric colorimeter (10). Five mgm. of bromsulphalein per kgm. of body weight were injected intravenously for this test and the retention was determined on a sample of plasma withdrawn after one-half hour. The readings were made in a photoelectric colorimeter. The colloid osmotic pressure was calcula...

Water Distribution in Normal Subjects and in Patients With Laënnec's Cirrhosis

“…The development of ascites and edema in patients with Laennec's cirrhosis is believed by some to be due to a deranged hormonal balance which results in salt and water retention (1)(2)(3)(4)(5). The present investigation analyzes the components of total body water in 22 control subjects and 15 patients with Laennec's cirrhosis to ascertain the distribution of the retained salt and water.…”

Production of Increased Renal Sodium Excretion by the Hypotonic Expansion of Extracellular Fluid Volume in Recumbent Subjects 1

“…In this condition the obviously increased volume of fluid below the diaphragm is not infrequently associated with clinical evidence of dehydration of the head, neck, arms and upper chest. These patients characteristically retain sodium with avidity, but in addition frequently exhibit hyponatremia (24,25) often~accompanied by relatively scanty urine of high specific gravity suggestive of ADH activity which indeed has been demonstrated by Ralli and colleagues (26). With improvement in liver function, the serum sodium tends to rise and the hematocrit to fall, the latter suggesting that an expansion of plasma volume has occurred, since it is unlikely that clinical improvement would be accompanied by either diminished blood formation or increased blood destruction.…”

Observations on the Alterations in Electrolytes and Fluid Balance in Patients With Cirrhosis of the Liver With and Without Ascites

“…However, administration of salt will increase fluid retention, body weight, edema and ascites ( Figures 1 and 2). Oliguria was not observed in cases maintained on restricted salt intakes, becoming evident that if an anti-diuretic principle is involved, as found by Ralli and associates (23) in cases with ascites, this agent must act through increasing salt retention.…”

“…The tration since the hematocrit values also decreased. concentration of protein in the plasma and in the In a third patient (P. F.) the plasma volume did ascitic fluid increased markedly, as noted in prenot change significantly; in the fourth case (A. vious studies (19)(20)(21)(22)(23) cr.r-r-w-v-v----ously observed (19)(20)(21)(22). Since the changes in the serum electrolytes and ascitic fluid electrolytes paralleled each other, only alteration 'in the serum electrolytes will be discussed.…”