Sodium restriction (20-30 mEq/d) and diuretic therapy constitute the standard medical management for
ascites and are effective in approximately 95% of patients.
Water restriction is used only if persistent hyponatremia is present (see Diet, below).
More recent research has focused on the treatment of refractory ascites with aquaretics
vasopressin V2-receptor antagonists that promote excretion of electrolyte-free water and thus might be
beneficial in patients with ascites and hyponatremia. [5] Although study results have been promising,
[6]
aquaretics still await approval by the Food and Drug Administration (FDA).
In a multicenter study that assessed the safety and efficacy of an automated pump system for the
treatment of refractory ascites in 40 patients at 9 centers, Bellot et al reported the automated pump was
an efficacious tool to remove ascites from the peritoneal cavity to the bladder.[7] During the 6-month followup period, 90% of the ascites was removed with the pump system; there was also a significant reduction
in the monthly median number of large volume paracentesis as well as a reduction in the number of
cirrhosis-related adverse events.[7]
Therapeutic paracentesis may be performed in patients who require rapid symptomatic relief for
refractory or tense ascites. When small volumes of ascitic fluid are removed, saline alone is an effective
plasma expander.[8] The removal of 5 L of fluid or more is considered large-volume paracentesis. Total
paracentesis, that is, removal of all ascites (even >20 L), can usually be performed safely.
Supplementing 5 g of albumin per each liter over 5 L of ascitic fluid removed decreases
complications of paracentesis, such as electrolyte imbalances and increases in serum creatinine levels
secondary to large shifts of intravascular volume. Note: The AASLD indicates that postparacentesis
albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L ((class I, level C
recommendation); however, for large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid
removed appears to improve survival and is recommended (class IIa, level C recommendation). [4]
To avoid exposing patients to blood products, the use of terlipressin (eg, 1 mg every 4 hours for 48
hours) rather than albumin has been proposed for prevention of circulatory dysfunction after large-volume
paracentesis. Initial studies suggest that terlipressin is as effective as albumin for this purpose. [9, 10]
Repeated therapeutic paracentesis can be used to treat refractory ascites (class I, level C
recommendation).[4] For palliative care in patients with advanced cancer, an alternative to serial
paracenteses is placement of an indwelling peritoneal catheter; ascitic fluid can then be removed by
continuous drainage[11] or intermittent drainage with a proprietary system utilizing vacuum bottles, which
can be performed in the patients home.[12] Preservation of good nutrition status is important.[13]
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiologic technique
that reduces portal pressure and may be the most effective treatment for patients with diuretic-resistant
ascites. In the procedure, which is performed with the patient under conscious sedation orgeneral
anesthesia, an interventional radiologist places a stent percutaneously from the right jugular vein into the
hepatic vein, thereby creating a connection between the portal and systemic circulations. TIPS is
gradually becoming the standard of care in patients with diuretic-refractory ascites.
Surgical Care
The peritoneovenous shunt is an alternative for patients with medically intractable ascites (see image
below).
Peritoneovenous shunt.
This is a megalymphatic shunt that returns the ascitic fluid to the central venous system. Beneficial effects
of these shunts include increased cardiac output, renal blood flow, glomerular filtration rate, urinary volume,
and sodium excretion and decreased plasma renin activity and plasma aldosterone concentration. Although
it has largely been supplanted by TIPS, peritoneovenous shunting has been shown to improve short-term
survival (compared with paracentesis) in cancer patients with refractory malignant ascites. [14] The AASLD
suggests considering peritoneovenous shunting for patients with refractory ascites who are not candidates
for paracentesis, transplant, or TIPS (class I, level A recommendation). [4]
The AASLD recommends that patients with cirrhosis and ascites be considered forliver
transplantation (class I, level B recommendation).[4]
Consultations
Consultation with a gastrointestinal specialist and/or hepatologist should be considered for all patients with
ascites, particularly if the ascites is refractory to medical treatment.
Diet
Sodium restriction of 500 mg/d (22 mmol/d) is feasible in a hospital setting; however, it is unrealistic in most
outpatient settings. A more appropriate sodium restriction is 2000 mg/d (88 mmol). Indiscriminate fluid
restriction is inappropriate. Fluids need not be restricted unless the serum sodium level drops below 120
mmol/L.
Perawatan medis
Pembatasan natrium (20-30 mEq / d) dan terapi diuretik merupakan manajemen
medis standar untuk asites dan efektif pada sekitar 95% pasien.
Pembatasan air hanya digunakan jika hiponatremia persisten hadir (lihat Diet, di
bawah).
Penelitian yang lebih baru telah difokuskan pada pengobatan asites refrakter
dengan aquaretics-vasopressin antagonis reseptor V2-yang mempromosikan
ekskresi air elektrolit bebas dan dengan demikian mungkin bermanfaat pada
pasien dengan asites dan hiponatremia. [5] Meskipun hasil penelitian telah
menjanjikan, [ 6] aquaretics masih menunggu persetujuan dari Food and Drug
Administration (FDA).
Dalam sebuah studi multicenter yang menilai keamanan dan kemanjuran sistem
pompa otomatis untuk pengobatan asites refrakter pada 40 pasien di 9 pusat,
Bellot et al melaporkan pompa otomatis adalah alat efektif untuk menghilangkan
ascites dari rongga peritoneum ke kandung kemih. [7] Selama masa tindak lanjut
6 bulan, 90% dari asites telah dihapus dengan sistem pompa; ada juga
penurunan yang signifikan dalam jumlah rata-rata bulanan paracentesis volume
besar serta pengurangan jumlah efek samping-sirosis terkait. [7]
Paracentesis terapi dapat dilakukan pada pasien yang membutuhkan bantuan
gejala cepat untuk asites refrakter atau tegang. Ketika volume kecil cairan asites
dihapus, garam saja merupakan plasma expander yang efektif. [8] Penghapusan
5 L cairan atau lebih dianggap besar volume paracentesis. Total paracentesis,
yaitu, penghapusan semua ascites (bahkan> 20 L), biasanya dapat dilakukan
dengan aman.
Melengkapi 5 g albumin per setiap liter lebih dari 5 L cairan asites dihapus
menurunkan komplikasi paracentesis, seperti ketidakseimbangan elektrolit dan
peningkatan kadar kreatinin serum sekunder pergeseran besar volume
intravaskular. Catatan: The AASLD menunjukkan bahwa postparacentesis
albumin infus mungkin tidak diperlukan untuk paracentesis tunggal kurang dari 4
sampai 5 L ((kelas I, rekomendasi tingkat C), namun untuk paracenteses volume
besar, infus albumin 6-8 g per liter cairan dikeluarkan muncul untuk
Shunt peritoneovena.
Shunt peritoneovena.
Ini adalah shunt megalymphatic yang mengembalikan cairan asites ke sistem
vena sentral. Efek menguntungkan dari shunt ini meliputi peningkatan curah
jantung, aliran darah ginjal, laju filtrasi glomerulus, Volume urin, dan ekskresi
natrium dan penurunan aktivitas renin plasma dan konsentrasi aldosteron
plasma. Meskipun sebagian besar telah digantikan oleh TIPS, shunting
peritoneovena telah ditunjukkan untuk meningkatkan kelangsungan hidup
jangka pendek (dibandingkan dengan paracentesis) pada pasien kanker dengan
ascites ganas refraktori. [14] The AASLD menyarankan mempertimbangkan
shunting peritoneovena untuk pasien dengan asites refrakter yang tidak calon
paracentesis, transplantasi, atau TIPS (kelas I, tingkat rekomendasi A). [4]
Konsultasi
Diet
Pembatasan natrium dari 500 mg / d (22 mmol / d) layak di rumah sakit; Namun,
itu tidak realistis dalam pengaturan rawat jalan yang paling. Pembatasan
natrium lebih tepat adalah 2000 mg / d (88 mmol). Pembatasan cairan
sembarangan adalah tidak pantas. Cairan tidak perlu dibatasi kecuali tingkat
natrium serum turun di bawah 120 mmol / L.