Refractory ascites

Liver transplantation should be considered in patients with refractory ascites. 

Decompensated liver disease is complicated by jaundice, refractory ascites, bacterial peritonitis, coagulopathy, and variceal bleeding and may require liver transplantation. The number of liver transplants for decompensated cirrhosis doubled from 1990 to 2004, when 5845 cadaveric (orthotopic) liver transplants were performed (65). 

Dexamethasone Testing of adrenal cortical hyperfunction cerebral edema associated with primary or metastatic brain tumor, craniotomy, or head injury. Tnamc/no/one Treatment of pulmonary emphysema where bronchospasm or bronchial edema plays a significant role, and diffuse interstitial pulmonary fibrosis (Hamman-Rich syndrome) in conjunction with diuretic agents to induce a diuresis in refractory CHF and in cirrhosis of the liver with refractory ascites and for postoperative dental inflammatory reactions. 

Larger volumes can only be safely removed if there is simultaneous albumin replacement intravenously (with about 8 g of albumin per litre of ascites). Synthetic plasma-expanders may not be greatly inferior to albumin in the short term. Transjugular intrahep-atic portal systemic shunting (TIPS) appears at least as effective as paracentesis in relieving refractory ascites without increasing mortality but with a raised risk of encephalopathy. 

Fig. 16.7 Massive refractory ascites with large umbilical hernia. Muscular atrophy and loss of subcutaneous fatty tissue...

Due to clinical, laboratory and therapeutic differences, it is possible to distinguish between simple and problematic ascites. The latter includes (I.) recurrent ascites, (2.) refractory ascites, (3.) diuretic resistant ascites, and 4.) diuretic intractable ascites, (s. tab. 16.8)... 

Before denoting ascites as refractory to conservative therapy in cases of liver cirrhosis, it is essential to rule out what would appear to be pathogenetically or causally derived resistance to therapy. The multiple causes of resistance to therapy must be considered in each individual case and excluded as far as possible. This can often be extremely difficult and is sometimes even impossible, (s. tab. 16.13) Assessment of the renal cortical blood flow is facilitated by colour-encoded Doppler sonography successful diuretic therapy of ascites requires good circulation in the renal cortex. A continuous decrease in the cortical blood flow correlates with growing therapy resistance of the ascites. 

With reliable cooperation on the part of the patient, precise adherence to stepwise therapy (possibly including repeated paracentesis) and almost total exclusion of the causes of therapy resistance, it becomes clear that true refractory ascites or sequestered ascites is present in merely 5-15% of patients with portal ascites. 

The prognosis of true refractory ascites is infaust -unless invasive measures can be applied. These would... 

In 1911 intravenous ascitic reinfusion was described as an invasive procedure to treat refractory ascites (I Galud). This procedure was taken up again by M. Girard et at in 1949 and by R. Emmrich et at in 1951. In 1958 E. Adlercreutz filtered the ascitic fluid prior to intraperitoneal reinfusion and thus increased its protein concentration. (172)... 

Fig. 16.13 Enonnous refractory ascites in alcoholic cirrhosis. Bilateral inguinal hernia with scrotal oedema. Muscular atrophy. Hepatic encephalopathy (II—III) (same patient as in fig. 16.14)...

After the positioning of a PVS, there was a survival rate of 40-67% after 1 year and 20-43% after 2 years, with a considerably improved quality of life. It is realistic to expect that a three-year survival rate can be achieved in 30-40% of these patients nowadays. Yet this calls for close adherence to and fulfilment of the criteria on risk reduction, (s. tab. 16.17) All instructions given to the patient must be duly observed (s. tab. 16.18, points 1-5), and the medical measures taken must be appropriate to the respective situation, (s. tab. 16.18, points 6—10) For patients with refractory ascites, the peri-toneovenous shunt or TIPS can provide real help in a situation that is otherwise hopeless ... 

Formerly, the possibilities of treatment were limited. At one time, 80 (-90)% of all ascites cases were considered to be refractory to therapy. Death could be expected within a short space of time. This explains the development of a multiplicity of surgical techniques - which seemed justifiable in spite of the high mortality rate (30-60%) - in order to achieve a longer survival time with a better quality of life for the individual. Despite sophisticated ideas, which indeed appeared to be logical at the time, these techniques generally proved inadequate and unfeasible in the long run. (s. tab. 16.19)... 

Tab. 16.19 Surgical attempts to eliminate refractory ascites (s. also tab. 19.7 )...

Transplantation of the liver essentially gives patients with refractory portal ascites a chance to start a new life. However, in the presence of large-scale ascites, the surgeon is faced with a number of specific problems such as overdilated and thin abdominal walls, existing hernia, spontaneous bacterial peritonitis, significant volume displace-... 

In all patients, conservative therapy is initially founded on basic and diuretic therapy, which is successful in 60-80% of cases. In individual instances, the therapeutic measures of stage III are recommended. Apparent refractory forms of ascites call for paracentesis (stage IV), unless there are reasons against this. Some 80-90% of all patients with portal ascites can be successfully treated conservatively. Given the appropriate indication, reinfusion of ascitic fluid is also feasible. 

Campra, J.L., Reynolds, T.B. Effectiveness of high-dose spironolactone therapy in patients with chronic liver disease and relatively refractory ascites. Dig. Dis. Sci. 1978 23 1025-1030... 

Salerno, F., Badalamenti, S., Lorenzano, E., Moser, R, Incerti, E Randomized comparative study of hemaccel vs. alhumin infusion after total paracentesis in cirrhotic patients with refractory ascites. Hepatology 1991 13 707-713... 

Smart, H.L., Triger, D.R. A randomised prospective trial comparing daily paracentesis and intravenous alhumin with recirculation in diuretic refractory ascites. J. Hepatol. 1990 10 191-197... 

Gines, E, Uriz, J., Calahorra, B., Garcia-Tsao, G., Kamath, P.S., Rnlz-del-Arbol, L., Planas, R., Bosch, J., Arroyo, V., Rodes, J. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002 123 ... 

Moral , G.A., Tobe, S.W., Skorecki, K.L., Blendis, L.M. Refractory ascites modulation of a trial natriuretic factor unresponsiveness by mannitol. Hepatology 1992 16 42-48... 

Schindler, C., Ramadori, G. Albumin substitution to improve renal excretion function in patients with refractory ascites. - An empirical account. Leber Magen Darm 1999 29 183-187... 

Lai, K.N., Leung, J.W.C., Vallance-Owen, J. Dialytic ultrafiltration by hemofilter in treatment of patients with refractory ascites and renal insufficiency. Amer. J. Gastroenterol. 1987 82 665—668... 

Bernhoft, R.A., Pellegrini, C.A., Way, L.W. Peritoneovenous shunt for refractory ascites operative complications and long-term results. Arch. Surg. 1982 117 631-635... 

Bories, R, Garcia Compean, D., Michel, H., Bourel, M., Capron, XR, Gauthier, A., Lafon, X, Levy, V.G., Pascal, XR, Quiton, A., Toumieux, B., Weill, XR The treatment of refractory ascites by the LeVeen shunt a multicentre controlled trial (57 patients). J. Hepatol. 1986 3 212-218... 

Grischkan, D.M., Cooperman, A.M., Hermann, R.E., Carey, W.D., Ferguson, D.R., Cook, S.A. Failure in LeVeen shunting in refractory ascites-A view from the other side. Surgery 1981 89 304-307... 

Rubinstein, D., Mclnnes, L, Dudley, F. Morbidity and mortality after peritoneovenous shunt surgery for refractory ascites. Gut 1985 26 1070-1073... 

Refractory ascites early experience in treatment with transjugular intrahepatic portosystemic shunt. Radiology 1993 189 795-801... 

Gerbes, A.L., Giilberg, V., Waggershauser, T., Holl, J., Reiser, M. Renal effects of transjugular intrahepatic portosystemic shunt in cirrhosis comparison of patients with ascites, with refractory ascites, or without ascites. Hepatology 1998 28 683-688... 

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