Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

164 Ascites

management

What to Do First

■Establish cause

■Determine SAAG

General Measures

■Low SAAG: management disease-specific & pts do not respond to

dietary salt restriction & diuretics

■High SAAG: dietary salt restriction & diuretics

specific therapy

Treatment Options: Routine

■Dietary sodium restriction to 2 g daily

■Oral diuretics, including spironolactone & furosemide

■Single 5 L paracentesis for tense ascites

Treatment Options: Refractory Ascites

■Liver transplantation

■Large-volume paracentesis: albumin infusion of 6–10 g/L of ascitic

fluid removed optional for paracentesis of >5 L

■Transjugular intrahepatic portosystemic shunt (TIPS)

■Peritoneovenous shunt

Side Effects & Contraindications

■Oral diuretics:

➣Side effects: renal failure, electrolyte disturbances, hepatic

encephalopathy and, with spironolactone, gynecomastia

➣Contraindications:

Absolute: serum creatinine >2.0 mg/dL, serum sodium <120

mmol/L

Relative: serum creatinine 1.5–2.0 mg/dL

■Liver transplantation:

➣Side effects: allograft rejection/dysfunction, surgical complica-

tions, infections

➣Contraindications: absolute: advanced cardiopulmonary dis-

eases, HIV seropositivity, extrahepatic malignancy, active sub-

stance abuse, medical noncompliance, anatomic anomalies pre-

cluding transplant surgery

■Large-volume paracentesis:

➣Side effects: asymptomatic changes in electrolytes & creatinine,

procedure-related complications