Ascites management

Portal hypertension

Portal hypertension is high blood pressure in the hepatic portal system which includes the portal veins and its branches which drains from most of the intestines to the liver. It is indicated when the hepatic venous pressure gradient exceeds 7 mmHg, while liver cirrhosis remains the most common cause which in our local setting is commonly caused by chronic viral hepatitis followed by heavy alcohol intake.

Clinical presentation

• Ascites

• Splenomegaly

• Esophageal varices and hematemesis

• Swollen veins of the anterior abdomen (caput medusa)

• Hemorrhoids

Investigations

• Radiological evidence of shrunken liver with typical features of cirrhosis

Ascites

Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and its most common cause is cirrhosis.

Pharmacological treatment of Ascites

• Spironolactone (PO) 50 mg – 400 mg 24 hourly, incrementally till ascites resolves

  
  

  OR

• Eplerenone (PO) 50 mg 24 hourly

  
  

  AND

• Furosemide (PO) 40 mg – 160 mg 24 hourly or in divided doses, incrementally till ascites resolves

AND

• Propranolol (PO) 40 mg – 160 mg 12 hourly daily, incrementally target heart rate 55–60 bpm

  
  

  OR

• Carvedilol (PO) 6.25 mg 24 hourly, increase to 6.25 mg (PO) 12 hourly unless persistent arterial hypertension, SBP should not decrease <90 mmHg

AND

• Albumin 25% (IV) – in refractory ascites and large volume paracentesis. Give 25 g stat, repeat at 15–30 min interval at max dose of 250 g/48 hourly

Note

• Consider discounting βB if SBP <90 or MAP ≤82 mmHg, serum Na <120 mEq/L, AKI, HRS, SBP, sepsis, severe alcoholic hepatitis, poor follow-up.

• Large-volume paracentesis (LVP; >5 L fluid removal): give 6–8 g albumin per L fluid removed (above 5 L) as colloid replacement is associated with decreased risk of post-paracentesis circulatory dysfunction and possibly decreased mortality.