Cirrhosis and ascites

Abstract

Abstract Ascites is the accumulation of fluid in the peritoneal cavity and the most common complication of cirrhosis, when it is associated with a poor prognosis. It occurs only when portal hypertension has developed and is mainly due to renal sodium retention secondary to splanchnic arterial vasodilation that leads to homeostatic activation of vasoconstrictor and sodium-retaining systems. Clinical presentation is with abdominal distension. The initial evaluation of a patient with ascites must include (1) history and physical examination; (2) liver and renal function tests including serum and urine electrolytes; (3) analysis of ascitic fluid (diagnostic paracentesis) for cell count and culture, and protein/albumin concentration; other tests such as cytology (suspicion of malignancy), amylase (pancreatic disease), and polymerase chain reaction and culture for mycobacteria (tuberculosis) should be done only when the diagnosis is unclear; (4) abdominal ultrasonography for evidence of cirrhosis, portal hypertension, or malignancy. First-line manoeuvres include dietary salt restriction, and therapeutic or total paracentesis. Water restriction is only recommended if there is severe dilutional hyponatraemia. Refractory ascites is managed by repeated paracentesis or insertion of a transjugular intrahepatic portosystemic shunt. Cirrhotic patients with ascites should be considered for liver transplantation. All patients with cirrhosis and ascites are at risk of spontaneous bacterial peritonitis (SBP). Typical symptoms are abdominal pain and fever, but the condition may be asymptomatic. Treatment with appropriate antibiotics should be started as soon as a presumptive diagnosis is made following diagnostic paracentesis. Mortality is around 10% for the acute episode and 75% at 1 year; hence (unless contraindicated), all patients with SBP should be considered for liver transplantation. Patients with cirrhosis and ascites are also at high risk of other complications.