Treatment for Ascites Due to Cirrhosis

Draining belly fluid

Liver

The effects of drinking too much alcohol or being infected with hepatitis is bad news for your liver and can cause cirrhosis, or chronic liver damage. The development of ascites, or excess fluid in your peritoneal cavity that causes abdominal swelling, is one symptom of cirrhosis. This abdominal swelling can press on your stomach and lungs, making it hard to eat and breath, respectively. Furthermore, this swelling causes abdominal discomfort and pain.

Most presentations of ascites result from cirrhosis of the liver (think viral hepatitis or alcoholic hepatitis) and involve extravasation, or leakage, of fluid that occurs on account of portal hypertension. To expatiate, conditions like heart failure and hepatitis cause hypertensive changes to the blood vessels (fibrosis), which affect the portal vein and portal venous system, or blood vessels that drain into the liver from the gut. These diseased vessels then leak fluid into the abdominal cavity. 

The development of ascites also results from the effects of a hormone called vasopressin. The body is programmed by vasopressin to retain fluid volume because circulatory volumes go down. Circulatory volumes go down because a lot of fluid volume is being "third spaced" or leaked into your abdominal cavity as ascites.

Other factors that contribute to the formation of cirrhotic ascites include sodium retention by the kidneys as well the impaired ability of the body to excrete, or get rid of, water.

Sodium retention contributes to the body's inability to generate free water. Finally, both these processes are augmented by vasopressin.

Because people with liver cirrhosis retain too much sodium to begin with, the prevention and management of ascites depends on th restriction of sodium consumed per day to 4 grams.

Diuretics and bed rest help drain excess water from the body. Furthermore, with most people who have ascites, there's no need to restrict the amount of water consumed.  Remember that water isn't the problem; salt is the problem.

It should be stressed that bed rest is a very important part of ascites treatment. Standing is bad for people with ascites because while standing more sodium is retained by the kidneys and less sodium is excreted.

Five percent of people with cirrhosis develop refractory cirrhosis, meaning that they fail to respond to dietary change and conventional diuretics. In these people, ascites can get really bad, making it difficult to breathe and move as well as causing fatigue. The appearance of refractory cirrhosis is dramatic with substantial abdominal distension that spreads the skin overlying the belly taut as a drum. 

For people with refractory ascites, a bolus or intravenous injection of a diuretic like furosemide may work. However, many people with refractory ascites need something more invasive: a therapeutic paracentesis, or adbominal tap.

With paracentesis, the excess fluid is tapped with a needle. Sometimes up to 5 liters is drained during an abdominal tap. 

A paracentesis can be done in an office setting, an emergency room setting or in the hospital. People with refractory ascites need paracentesis once the fluid builds back up again. About 60 percent of people with refractory ascites find relief in the form of a shunt (transjugular intrahepatic portosystemic shunt or TIPS). A shunt is a longer-term solution for the build-up of ascites; however, shunt placement results in a higher frequency of adverse effects--most notably encephalopathy.

The best way to treat ascites is to treat what's causing the ascites--to get to the root of the problem and treat that instead of treating a symptom. For most people with advanced cirrhosis, the definitive treatment is liver transplant.

On a final note, other conditions--like congestive heart failure, bacterial peritonitis, lymphoma and ovarian cancer and uterine cancer--can also cause ascites. The characteristics and appearance of the ascites in these different conditions differs from ascites secondary to cirrhosis.  Furthermore, these other types of ascites are produced through some different mechanisms, and the diseases that cause these different types of ascites are treated differently, too.

Selected Sources

Greenberger NJ. Ascites & Spontaneous Bacterial Peritonitis. In: Greenberger NJ, Blumberg RS, Burakoff R. eds. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 3e. New York, NY: McGraw-Hill; 2016. Accessed January 04, 2016.

 

 

 

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