Management of Ascites due to Cirrhosis

Management of Ascites due to Cirrhosis

Analysis of ascites A diagnostic paracentesis should be performed in all cirrhotic patients with ascites on hospital admission. A diagnostic paracentesis should be performed in all cirrhotic patients with ascites who have signs and symptoms of peritoneal infection, including the development of encephalopathy, renal impairment, or peripheral leucocytosis without a precipitating factor. Patients should give informed consent for a therapeutic or diagnostic paracentesis. The initial ascitic fluid analysis should: Include serum ascites-albumin gradient in preference to ascitic protein. Ascitic amylase should be measured when there is clinical suspicion of pancreatic disease Ascitic fluid should be inoculated into blood culture bottles at the bedside and examined by microscopy for a neutrophil count. Serum ascites-albumin gradient (SA-AG) SA-AG >11 g/l SA-AG <11 g/l Cirrhosis Malignancy Cardiac failure Pancreatitis Nephrotic syndrome Tuberculosis Management of ascites Bed Rest Bed rest is NOT recommended for the treatment of ascites. Dietary salt Dietary salt should be restricted to a no-added salt diet of 90 mmol salt/day (5.2 g salt/day). Diuretics First line treatment of ascites should be spironolactone alone, increasing from 100 mg/day to a maximum dose of 400 mg/day. Note this may take 48 hours to work. If this fails to resolve ascites, furosemide should be added. The initial dose should be furosemide 20mg increasing gradually to a maximum dose of 160 mg/day if required. This should be done with careful biochemical and clinical monitoring. Note that most clinicians would start furosemide when you have reached a dose of spironolactone of 200-300mg/day. Aim to lose ~0.5kg/day
1
Location of master copy: Clinical Director (Gen Medicine) Version 2 Approved: 6th May 2010 at Medicines Management Committee Date of Review: May 2012

Management of Ascites due to Cirrhosis

Electrolytes Serum sodium 126135 mmol/l, normal serum creatinine. Continue diuretic therapy but observe serum electrolytes. Do not water restrict. Serum sodium 121125 mmol/l, normal serum creatinine. International opinion is to continue diuretic therapy, BSG opinion is to stop diuretic therapy or adopt a more cautious approach. Serum sodium 121125 mmol/l, serum creatinine elevated (>150 mol/l or >120 mol/l and rising). Stop diuretics and give volume expansion. Serum sodium <120 mmol/l, stop diuretics. Management of these patients is difficult and controversial. BSG believes that most patients should undergo volume expansion with colloid (haemaccel, gelofusine, or voluven) or saline. However, avoid increasing serum sodium by >12 mmol/l per 24 hours. Therapeutic paracentesis Therapeutic paracentesis is the first line treatment for patients with large or refractory ascites. Large volume paracentesis should be performed in a single session with volume expansion being given (100ml of 20% albumin for every 2.5 litres of ascites drained or 500ml of 4.5% albumin for every 2.5 litres of ascites drained) Drains are to be removed after 8 hours Spontaneous Bacterial Peritonitis (SBP) Diagnosis & Treatment In patients with an ascitic fluid neutrophil count of >250 cells/mm3, empiric antibiotic therapy should be started. Result should be available within 2 hours. The person who does the diagnostic paracentesis must document it. See below for parenteral therapy if unwell, or co-amoxiclav 500/125 mg tds orally for 5 days. Patients with SBP and signs of developing renal impairment should be given albumin at 1.5 g albumin/kg in the first six hours followed by 1 g/kg on day 3. Diagnostic paracentesis should be repeated if patient develops signs/symptoms of infection, even if previous tap was not diagnostic of SBP. Spontaneous Bacterial Peritonitis (SBP) - Prophylaxis Patients recovering from one episode of SBP should receive prophylaxis with continuous oral norfloxacin 400 mg/day (or ciprofloxacin at 500 mg once daily). All patients with SBP should be considered for referral for liver transplantation. In patients with low total ascitic protein (<10g/l), consider prophylactic antibiotics, taking into account risk of resistance.

2
Location of master copy: Clinical Director (Gen Medicine) Version 2 Approved: 6th May 2010 at Medicines Management Committee Date of Review: May 2012

Management of Ascites due to Cirrhosis

Antibiotic management of Spontaneous bacterial peritonitis; If parenteral therapy is required: First line if: <65yrs- IV Co-amoxiclav 1.2 gms 8hrly for 5 days if 65 yrs- IV Pipericillin-tazobactam 4.5gms 8 hrly for 5 days For mild penicillin allergy: IV Cefuroxime 750mg 8 hrly + IV Metronidazole 500mg 8hrly x 5 days For penicillin anaphylaxis- discuss with microbiology

Adapted from: Guidelines on the management of ascites in cirrhosi; K P Moore and G P Aithal.Gut 2006; 55(Suppl VI):vi1vi12.

Author: Dr Ashwin Verma, Consultant Gastroenterologist

Consultation with: Consultant Gastroenterologists: Dr Rob Atkinson, Dr Susan Jones, Dr George Sobala, Dr Sunil Sonwalkar Consultant Microbiologists: Dr David Birkenhead, Dr Anu Rajgopal

3
Location of master copy: Clinical Director (Gen Medicine) Version 2 Approved: 6th May 2010 at Medicines Management Committee Date of Review: May 2012