35 36 37 (3) Ascites.docx

Ascites Learning Objectives For the following complications of cirrhosis, describe: Pathophysiology Non-pharmacologic management strategies Pharmacologic management strategies, including dosing Primary and secondary prophylaxis, including dosing, when applicable Complications: portal hypertension, v...

Ascites Learning Objectives For the following complications of cirrhosis, describe: Pathophysiology Non-pharmacologic management strategies Pharmacologic management strategies, including dosing Primary and secondary prophylaxis, including dosing, when applicable Complications: portal hypertension, varices, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome Definition of Ascites Definition: accumulation of >25mL lymph fluid in peritoneal cavity due to portal hypertension SAAG score for confirmation Pathophysiology Part 1 Causes Step 1: Liver fibrosis due to cirrhosis causes resistance to blood flow in the portal vein Splanchnic vasodilation leads to arterial underfilling (hypotension) Step 2: NO and hypotension activates RAAS system Lead to sodium and water retention RAAS Reminder Renin release from juxtaglomerular cells in kidney Cleavage of angiotensinogen to angiotensin I in liver Angiotensin Converting Enzyme (ACE) cleaves angiotensin I to angiotensin II Angiotensin II binds and activates AT1 receptor ↑ adrenal aldosterone production ↑ sodium retention and ↑ potassium excretion (ANTIDIURETIC EFFECT!) ↑ arterial perfusion pressure -> regulating renin release! Pathophysiology Part 2 Albumin Cirrhosis = liver can’t effectively make albumin Presentation Diagnosis Physical Exam: Large abdomen, fluid wave, abdominal pain Abdominal US Paracentesis (diagnostic +/- therapeutic) SAAG (serum-ascites albumin gradient) = albumin in serum – albumin in ascetic fluid SAAG ≥1.1 g/dL and Ascitic Protein <2.5 g/dL indicates fluid accumulation is due to portal hypertension (97% specific) SAAG ≥1.1 g/dL and Ascitic Protein ≥ 2.5 g/dL indicates a cardiac source SAAG <1.1 g/dL indicates another cause such as cancer, TB, heart failure, pancreatic disease Paracentesis Classification of Ascites Grade Detection Responsiveness to Treatment Definition of Responsiveness Grade 1: mild Only via US Responsive Fully mobilized or limited with Na restriction/ diuretics Grade 2: moderate Moderate abd distension Recurrent Recurs at least 3x within 12 mo Grade 3: large or gross Marked abd distension Refractory Not mobilized or early recurrence after large volume paracentesis – not prevented by diuretics Consider referring Grade 2 and 3 for liver transplant Non-pharmacologic Treatment Diet: abstinence from alcohol, sodium restriction to <2g/day Diuretics First episode: spironolactone may be used alone Long-standing: initiate furosemide 40 mg PO QAM and spironolactone 100 mg PO QAM Increase doses prn (interval at least q72hr) but maintain 40:100 ratio max daily dose: furosemide 160mg and spironolactone 400mg Alternative Diuretics Suboptimal response to furosemide- can switch to torsemide or bumetanide If spironolactone painful gynecomastia, consider amiloride or triamterene Monitoring Daily weights (at same time each day) No Peripheral edema: weight loss should be <0.5kg/day Peripheral edema: weight loss up to 1 kg/day Adverse effects Low BP Hyperkalemia = spironolactone Hypokalemia = furosemide Hyponatremia = furosemide ↑ Serum Creatinine = both Muscle cramps (unknown etiology) = both Replete electrolytes (K, Mg) Other treatments: baclofen, albumin When ascites is adequately mobilized, taper diuretics to lowest effective dose to maintain minimal or no ascites Grade 3 Ascites Treatment Therapeutic paracentesis for Grade 3 Rapid large-volume paracentesis >5L can cause circulatory collapse, encephalopathy, and renal failure (HRS) ONLY if >5L removed: prevent above complications with IV albumin 6-8g per L of ascetic fluid that is removed After LVP, diuretics can be started for maintenance Ascites Medications to discontinue: NSAIDs, nephrotoxic, ACEi/ARB, aminoglycosides TIPS (Transjugular Intrahepatic Portosystemic Shunt) For ascites not responsive to diuretics and sodium restriction