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Treatment of ascites in cirrhosis. Diuretics, peritoneovenous shunt, and large-volume paracentesis
Insights
Spironolactone is a key diuretic for ascites in cirrhosis. Large-volume paracentesis with albumin is now the preferred treatment for tense ascites, offering better outcomes and fewer complications than diuretics alone.
Area of Science:
- Hepatology
- Gastroenterology
- Internal Medicine
Background:
- Ascites in cirrhosis is primarily managed with sodium restriction and diuretics.
- Spironolactone is a foundational diuretic due to its potent natriuretic effect in sodium-retaining cirrhotic patients.
- Combined spironolactone and furosemide enhance natriuresis while mitigating potassium disturbances.
Purpose of the Study:
- To review current and emerging treatments for ascites in cirrhosis.
- To compare the efficacy and safety of diuretic therapy versus paracentesis with albumin infusion.
- To discuss alternative and adjunctive therapies for refractory ascites.
Main Methods:
- Review of recent studies on ascites management in cirrhosis.
- Comparison of diuretic therapy, large-volume paracentesis with albumin, and peritoneovenous shunting.
- Analysis of treatment-associated complications and patient outcomes.
Main Results:
- Large-volume paracentesis with albumin infusion is more effective than diuretics for ascites elimination.
- This procedure is linked to reduced complications like hepatic encephalopathy and renal impairment, and shorter hospital stays.
- Peritoneovenous shunting is an option for diuretic-resistant ascites but carries a high complication rate.
Conclusions:
- Therapeutic paracentesis with albumin infusion is the treatment of choice for tense ascites in cirrhosis.
- While diuretics are needed to prevent reaccumulation post-paracentesis, paracentesis offers superior outcomes.
- Peritoneovenous shunts are reserved for refractory cases due to significant procedural risks and prosthesis obstruction.
Abstract:
The medical treatment of ascites in cirrhosis is based on sodium restriction and the administration of diuretics. Because the natriuretic potency of spironolactone is greater than that of loop diuretics (i.e., furosemide) in patients with marked sodium retention, spironolactone is the basic drug for the treatment of ascites. The simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism. Recent studies indicate that large-volume paracentesis associated with intravenous albumin infusion is more effective than diuretic therapy in eliminating the ascitic fluid; is associated with a lower incidence of complications (hepatic encephalopathy, renal impairment, and hyponatremia); and considerably reduces the duration of hospital stay. Therapeutic paracentesis associated with intravenous albumin infusion is therefore the treatment of choice for cirrhotic patients with tense ascites. The mobilization of the ascitic fluid by paracentesis without plasma volume expansion is constantly associated with a deterioration of effective circulating blood volume and may induce renal impairment and severe hyponatremia. Dextran 70 and polygeline appear as effective as albumin in preventing these abnormalities. Cirrhotic patients treated with paracentesis require the administration of diuretics to avoid reaccumulation of ascites. Peritoneovenous shunt, a prosthesis capable to correct most abnormalities involved in the accumulation of fluid in the abdominal cavity, is an effective treatment of ascites in cirrhosis. It is especially indicated in patients who do not respond to diuretics and develop repeated episodes of ascites despite adequate treatment. The use of peritoneovenous shunting is limited by the high incidence of complications induced by the procedure, however. In addition, approximately 40% of patients develop an obstruction of the prosthesis within the first postoperative year.