Management of cirrhotic ascites

Pedersen, Julie Steen; Bendtsen, Flemming; Möller, Sören

doi:10.1177/2040622315580069

Cited by 60 publications

(121 citation statements)

References 118 publications

(151 reference statements)

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“…The remaining cases can be explained by infective, inflammatory and infiltrative pathologies such as pancreatitis, malignancy and tuberculosis [1]. In patients with portal hypertension and cirrhosis, the development of ascites is a poor prognostic marker, with 50% mortality at 3 years [2].…”

Section: Introductionmentioning

confidence: 99%

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome

Pericleous

Sarnowski

Moore

et al. 2016

European Journal of Gastroenterology & Hepatology

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Several pathogenic processes have been implicated in the development of abdominal ascites. Portal hypertension, most usually in the context of liver cirrhosis, can explain about 75% of the cases, whereas infective, inflammatory and infiltrative aetiologies can account for the rest. In this article, we discuss the consensus best practice as published by three professional bodies for the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). The aim of this study was to compare available clinical guidelines and identify areas of agreement and conflict. We carried out a review of the guidance documentation published by three expert bodies including the British Society of Gastroenterology, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD), as well as a wider literature search for ascites, SBP and HRS. Abdominal ultrasonography, diagnostic paracentesis and ascitic fluid cultures are recommended by all three guidelines, especially when there is strong clinical suspicion for infection. EASL and AASLD advocate the use of ascitic amylase and mycobacterial cultures/PCR when there is strong suspicion for tuberculosis and pancreatitis, respectively. Ascitic cytology can be useful when cancer is suspected and has a good diagnostic yield if performed correctly. EASL supports the use of urinary electrolytes for all patients; however, the British Society of Gastroenterology and AASLD only recommend their use for therapy monitoring. All three societies recommend cefotaxime as the antibiotic of choice for SBP and large-volume paracentesis for the management of ascites greater than 5 l in volume. For HRS, cautious diuresis, volume expansion with albumin and the use of vasoactive drugs are recommended. There appears to be good concordance between recommendations by the European, American and British guidelines for the management of ascites and the possible complications arising from it.

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Section: Introductionmentioning

confidence: 99%

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome

Pericleous

Sarnowski

Moore

et al. 2016

European Journal of Gastroenterology & Hepatology

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“…Both of these findings have been described as suggestive of the diagnosis of tuberculous peritonitis [3,4]. In addition, the ADA test was demonstrated by a meta-analysis to have a high sensitivity and high specificity for revealing tuberculous peritonitis in ascitic fluid [1]. However, it should be noted that the ADA can also be elevated in the setting of malignancy [5].…”

Section: Discussionmentioning

confidence: 99%

“…Portal hypertension due to cirrhosis is the most common cause of ascites [1], and would certainly be the most likely etiology of ascites in any patient with a prior history of chronic liver disease. Paracentesis provides both therapeutic and diagnostic benefit, allowing for fluid analysis that may identify its etiology, clarifying the source of pathology as either hepatic, cardiac, infectious or malignant.…”

Section: Introductionmentioning

confidence: 99%

A Case of Metastatic Gastric Signet Ring Cell Carcinoma Presenting as Tuberculous Peritonitis in an HIV/HCV Coinfected Patient

Gadani¹,

Yfantis²,

Xie³

et al. 2017

Colorec Cancer

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Portal hypertension due to cirrhosis is the most common cause of ascites. However, in patients with multiple risk factors for ascites, determining the etiology can sometimes present a diagnostic challenge. We present a case of new onset ascites in a 59 year old African American man with concomitant HIV (CD4 54) and chronic active hepatitis C infection, and suspected tuberculosis corroborated by elevated Adenosine Deaminase (ADA). In this unusual case, despite suggestive symptoms and signs, we found the cause of his ascites was neither infection nor liver disease, but rather metastatic gastric malignancy. Ultrasound with Doppler did not show cirrhotic features or vascular thrombus in the liver, while diagnostic and therapeutic paracentesis revealed a low Serum AlbuminAscites Albumin Gradient (SAAG) and high ascitic fluid WBC count with monocytic predominance. Repeat ascitic fluid testing confirmed low SAAG, and ADA was elevated at 26.3 IU/mL. Laparoscopy revealed innumerable peritoneal lesions resembling tuberculous seeding of the peritoneum. However, peritoneal histopathology returned as metastatic signet cell adenocarcinoma. Esophagogastroduodenoscopy (EGD) revealed a large, firm, ulcerated gastric body tumor, and pathology was consistent with diffuse signet ring cell carcinoma. In this case, cirrhosis and tuberculous infection were highly suspected, however there was no evidence of cirrhosis, and although acid-fast smear and Quantiferon testing were negative, tuberculous peritonitis was strongly considered due to history of HIV and high monocyte predominance of ascitic fluid with elevated ADA. Both findings are suggestive of tuberculous peritonitis, however, ADA can also be elevated in the setting of malignancy and the pre-test probability of tuberculosis should be considered when sending ADA levels. Confirmation of the diagnosis with peritoneal biopsy is paramount.

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“…It has been conirmed that intravenous albumin is the most efective plasma expander when more than 5 l of ascites is removed [3][4][5] ( Table 3).…”

Section: Grade 3 Ascitesmentioning

confidence: 96%

Introductory Chapter: Treatment of Ascites Associated with Cirrhosis and Its Complications

Rodrigo¹

2017

Ascites - Physiopathology, Treatment, Complications and Prognosis

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Management of cirrhotic ascites

Cited by 60 publications

References 118 publications

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome

A Case of Metastatic Gastric Signet Ring Cell Carcinoma Presenting as Tuberculous Peritonitis in an HIV/HCV Coinfected Patient

Introductory Chapter: Treatment of Ascites Associated with Cirrhosis and Its Complications

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