Ascities Flashcards
What is the most common complication of cirrhosis
Ascites - most common hospital admission
what is the life expectancy of a cirrhosis patient with ascities?
50% death rate in 5 years w/ ascites present
Ascities physical exam
Full tense bulging abdomen
Trouble breathing
Ascites diagnosis criteria
Abdominal ultrasound –> tells you the presence of fluid but not why (could be due to HF or cirrhosis who knows)
Abdominal paracentesis –> get SAAG (serum alb – ascities alb)
- if SAAG ≥1.1 (portal HTN present, blood shunt, fluid collects)
Treating Ascities
+ Restrict sodium (max 2g/day)
DO NOT FLUID RESTRICT, already low volume
KEEP RATIO: Spironolactone 100mg : Furosemide 40mg
+ Aldosterone antagonist (spironolactone)
* start 50-100mg, can go up to 400mg if tolerated
* WATCH OUT FoR HYPERKALEMIA
+ Loop diuretic (furosemide)
* start 40mg QD, can go up to 160mg QD if tolerated
+/- Midodrine if BP concerningly low
What do if the patient no longer responds to diuretic therapy? (diuretics ineffective, or BP still low despite midodrine)
Large volume paracentesis (4-8L removal)
–> removal will cause BP drop and elevated SCr
if >5L removed, treat with IV albumin (hypertonic)
+IV administer 8g of 25% albumin for EVERY LITER OF FLUID REMOVED
–> 5L removed = 40g of 25% albumin
–> 8L removed = 64g of 25% albumin
Risk/benefits of IV albumin
Cons: short half life, lasts ~6hrs only, VERY expensive $$$
Pros: Morality benefit!! keeps fluid intravascular
What do we do if the patient failed diuretic therapy and also can’t tolerate large-volume paracentesis?
Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure
–>Bloodflow bypasses the liver
Problems: no more liver metabolism
– Ammonia high –> hepatic encephalopathy
What other cases do we use the TIPS procedure?
Refractory variceal bleeding
Ascites treatment failure
AE of TIPS procedure
40% patients get hepatic encephalopathy
When is the TIPS procedure contraindicated
when patient has a history of hepatic encephalopathy
