Treatment of Ascites: Old and New Remedies

Abstract

Ascites is a common complication of chronic liver disease. Treatment of the underlying liver disease with modalities such as abstinence from alcohol in Laennec’s cirrhosis, phlebotomy in hemochromatosis, copper removal in Wilson’s disease, and steroids in autoimmune liver disease, can improve survival in many patients. In addition, therapy of ascites alleviates the symptoms and improves the quality of life of the patients, and probably decreases the incidence of life-threatening conditions including spontaneous bacterial peritonitis and hepatorenal syndrome. The mean survival rate at 2 years is approximately 50%. Precipitating factors such as gastrointestinal bleeding, nonsteroidal anti-inflammatory drugs and infections, should be identified, since most of them can be corrected. Most cirrhotics with ascites can be managed with a ‘step-by-step’ approach, including dietary salt restrictions, aldosterone antagonists, and loop diuretics. When tense or refractory ascites is present, large-volume paracentesis is safe and effective. Peritoneovenous shunting (i.e. Denver, LeVeen) is less frequently used because of perioperative morbidity and mortality, and thrombotic complications with occlusion of the stent. Reinfusion of concentrated ascites is of potential benefit and has been used in Europe. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative procedure performed by interventional radiologists that allows decompression of portal hypertension. In many cases, ascites is improved after TIPS, but long-term randomized trials for tense or refractory ascites comparing TIPS with standard therapy are not conclusive. Liver transplantation is the ultimate step for the treatment of ascites, providing the cure for the underlying liver disease as well. Transplantation is indicated when quality of life of the patient is impaired due to recurrent episodes of ascites, or in the presence of spontaneous bacterial peritonitis and hepatorenal syndrome.

Refractory Ascites After Liver Transplantation: An Analysis of 1058 Liver Transplant Patients at a Single Center

“…Patients with RA usually have additional complications, including spontaneous bacterial peritonitis, hepatorenal syndrome and hepatic hydrothorax (3–4). Large volume paracentesis (LVP), a transjugular intrahepatic portosystemic shunt (TIPS), peritoneovenous shunts and portocaval shunts have all been used (1–9) in treating patients with RA. Liver transplantation (LT) is the best therapeutic option for patients with end‐stage liver disease and ascites, because the ascites usually disappears after LT. Ascites after LT has been reported, and its occurrence has been associated with hepatic vein outflow obstruction (10–12).…”

Percutaneous peritoneovenous shunt positioning: technique and preliminary results

“…Peritoneovenous shunt devices were developed in order to permit the continuous reinfusion of the ascitic fluid [3]. Because of the surgical approach needed, the implantation of these devices requires a careful selection of the patients, taking into account their prognosis and the possible real benefit which can be obtained by the shunt.…”

“…The ideal treatment should aim to control the symptomatology and improve quality of life, with the least patient discomfort. The treatments commonly used, such as fluid restriction with diuretics, repeated paracenteses, intracavitary and external beam radiotherapy, systemic or intraperitoneal chemotherapy, and immunotherapy, all allow symptom palliation with poor, temporary, and generally unsatisfactory results [1,2,3,4].…”

Peritoneocystic Shunting for Ascites

“…According to some reports, the insertion of this type of shunt is associated with a subclinical disseminated intravascular coagulation in all patients and can cause thrombophlebitis and clinically significant disseminated intravascular coagulation in 5 to 10 per cent of patients, which requires removal of the device. 2,3 Furthermore, a high percentage of patients have a postoperative course complicated by sepsis and thromboembolic events. 4,5 More patients could become free from the problems associated with tense ascites if a device could be implanted in the abdomen with the ascitic fluid shunted into the bladder.…”