Diuretic-resistant Ascites Research Articles

Transjugular intrahepatic portosystemic shunt or a combination of nonselective beta blockers and endoscopic variceal ligation for prophylaxis of bleeding in waitlisted cirrhotic patients

Objective: to substantiate the choice of an optimal method of preventing and reducing the risk of variceal bleeding (VB) and cardia in patients with decompensated cirrhosis who have been enlisted for liver transplantation (LT).Materials and methods. Patients with diuretic-resistant and diuretic-responsive ascites underwent prophylaxis for recurrent bleeding via transjugular intrahepatic portosystemic shunt (TIPS) or a combination of endoscopic variceal ligation (EVL) and nonselective beta-blockers (NSBB).Results. Leukocyte counts, Na levels, and Child–Turcotte–Pugh (CTP) liver disease class in patients with diuretic-resistant ascites had significant differences when comparing individuals who received EVL + NSBB or underwent TIPS. In diuretic-responsive patients, there were significant differences for blood platelet count, albumin and Na levels, and CTP class when comparing EVL + NSBB and TIPS groups. In diuretic-resistant patients, incidence of grade 2 varices in EVL + NSBB group was significantly higher than in TIPS. Incidence of grade 3 varices was significantly higher in TIPS patients than in EVL + NSBB cohort. In diuretic-responsive patients, incidence of grade 2 and 3 varices had no significant differences when comparing these indicators in both groups. The proportion of patients with CTP class B was significantly higher both in diuretic-resistant and diuretic-responsive patients with various methods of rebleeding prophylaxis. The proportions of CTP class C patients with both forms of ascites were significantly higher in EVL + NSBB group than in TIPS. During the LT wait period within 2 years from the start of bleeding prophylaxis in diuretic-resistant patients, 78.4% of patients who underwent TIPS implantation developed recurrent bleeding, 100% of EVL + NSBB group within the same time frame, developed recurrent bleeding. Using the Kaplan–Meier estimate with the Log-Rank test, we were able to establish that there is a significant difference between the proportions of patients with recurrent VB in EVL + NSBB or TIPS groups with both forms of ascites.

Liver transplantation in Budd–Chiari patients with history of portacaval shunt surgery

The paper presents the experience of successful treating a patient with diuretic-resistant ascites associated with Budd– Chiari syndrome. The authors provide a clinical observation of deceased donor liver transplantation to a patient with Budd–Chiari syndrome type 1, total hepatic vein occlusion, and diuretic-resistant ascites after portacaval shunt surgery. The post-transplantation period is observed as stable, with no signs of liver failure; ascites is reduced. The first experience of surgical treatment of a patient with Budd–Chiari syndrome, as well as the first experience of liver transplantation after portacaval shunting is appeared to be successful.

Outpatient albumin infusions reduce hospitalizations and improve outcomes in decompensated cirrhosis: A real-world cohort study.

Long-term human albumin (HA) infusions improve survival in cirrhotic patients with diuretic resistant ascites. We aimed to determine whether there is a significant benefit in a more unwell real-world cohort. This is a single-center retrospective cohort study. Patients received outpatient HA between April 2017 and June 2021. Inclusion criteria were age ≥18 years, cirrhosis with ascites, and received at least 1 month of HA. Patients with significant comorbidities and ongoing alcohol use were not excluded. Outcomes assessed were transjugular intrahepatic portosystemic shunt (TIPS)/transplant-free survival (TTFS), and biochemical and prognostic outcomes. Twenty-four patients were included. Median age was 59.5 years. Seven were female (29.2%). Etiology included were alcohol (50%), non-alcoholic steatohepatitis (16.7%), and viral/alcohol (12.5%). Median model for end-stage liver disease-sodium (MELD-Na) was 18.5, with Child-Pugh scores (CPS) A (4.2%), B (50%), and C (45.8%). Improvements in serum sodium (P = 0.014), albumin (P = 0.003), and CPS (P = 0.017) were observed. Reduction in hospitalizations (P = 0.001), particularly portal hypertensive related admissions was observed (relative risk 0.39; 95% confidence interval [CI] 0.21-0.69, P = 0.003), needed to treat 2.09 (95% CI 1.25-3.67). There was a reduction in total paracentesis requirements (P = 0.005). On multivariate analysis, type 2 diabetes mellitus significantly increased risk of TIPS/transplant/death (hazard ratio 6.16; 95% CI 1.23-30.84, P = 0.027). Median TTFS improved in patients with a change in MELD-Na ≤1 at 1 month: 29.4 months versus 7.7 months (P = 0.011). Outpatient HA infusions decrease portal hypertensive related hospital admissions, improve serum sodium, albumin levels, and CPS. Type 2 diabetes mellitus and change in MELD-Na score help discriminate those likely to benefit most.

Effect of beta-blockers on multiple haemodynamics in cirrhosis: A cross-over study by MR-imaging and hepatic vein catheterization.

Non-selective beta-blockers (NSBB) are widely used in the treatment of patients with cirrhosis. Only about 50% respond with a sufficient reduction in their hepatic venous pressure gradient (HVPG) and NSBB may induce detrimental cardiac and renal effects in the presence of severe decompensation. We aimed to assess the effects of NSBB on haemodynamics using magnetic resonance imaging (MRI) and to assess if these haemodynamic changes were related to the disease severity and HVPG response. A prospective cross-over study of 39 patients with cirrhosis. Patients underwent hepatic vein catheterization and MRI with assessments of HVPG, cardiac function, systemic and splanchnic haemodynamics before and after propranolol infusion. Propranolol induced significant decreases in cardiac output (-12%) and blood flow of all vascular compartments, with the largest reductions seen in the azygos venous (-28%), portal venous (-21%), splenic (-19%) and superior mesenteric artery (-16%) blood flow. Renal artery blood flow fell by -5% in the total cohort, with a more pronounced reduction in patients without ascites than in those with ascites (-8% vs. -3%, p = .01). Twenty-four patients were NSBB responders. Their changes in HVPG after NSBB were not significantly associated with other haemodynamic changes. The changes in cardiac, systemic and splanchnic haemodynamics did not differ between NSBB responders and non-responders. The effects of acute NSBB blockade on renal flow seem to depend on the severity of the hyperdynamic state, with the largest reduction in renal blood flow in compensated patients compared to decompensated patients with cirrhosis. However, future studies are needed to assess the effects of NSBB on haemodynamics and renal blood flow in patients with diuretic-resistant ascites.

Use of endoscopic band ligation alone and in combination with nonselective beta blockers for prevention of variceal bleeding in ascites patients on the liver transplant waiting list

Objective: to conduct a comparative analysis of the effectiveness of two methods – endoscopic band ligation (EBL) alone and in combination with nonselective beta blockers (NSBB) – used for prevention of variceal bleeding (VB); to evaluate their impact on patient survival in severe ascites during long-term stay on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of two groups of patients with decompensated liver disease, ascites and varices included in the LTWL, who received EBL (n = 41, group 1) and EBL + NSBB (n = 45, group 2). Results. The groups being compared did not differ in demographics, clinical parameters, MELD and Child–Turcotte–Pugh scores. There were no significant differences in the incidence of severe ascites, particularly diuretic-resistant ascites. The study groups did not differ in the incidence of mediumand large-sized varices. Incidence of bleeding did not differ in both groups. Overall mortality was significantly higher in the EBL + NSBB group than in the EBL group. Patient survival was lower, while mortality was higher in the EBL + NSBB group. The combined therapy group had a significantly higher number of acute kidney injury (AKI) than the EBL group. Conclusion. The compared methods are equivalently effective in preventing VB in patients with decompensated cirrhosis with a prolonged stay on the waiting list. Survival rate is significantly lower, while mortality is significantly higher in the EBL + NSBB group than in the EBL group.

Ultrastructural observation of filtration membrane in cell-free and concentrated ascites reinfusion therapy for malignant ascites.

IntroductionCell‐free and concentrated ascites reinfusion therapy (CART) is used for the treatment of diuretic‐resistant ascites. An increase in circuit pressure and clogging of the filtration membrane often occur in CART for malignant ascites.MethodsTo clarify the precise mechanism of filter clogging, we performed an ultrastructural observation study of the filtration membrane after the filtration of malignant ascites.ResultsThe deposition on the filtration membrane was composed of blood cells, fibrin, or both. Cellular deposition was associated with a greater number of blood cells in the original ascites fluid. In contrast, fibrin deposition was associated with higher levels of interleukin‐6, α1‐antitrypsin, haptoglobin, and fibrinogen/fibrin degradation products.ConclusionOur results suggest that the specific pathophysiologies of malignancy (such as inflammation or coagulation/fibrinolysis) and characteristics of malignant ascites (highly concentrated and cell‐rich) are associated with clogging of the filtration membrane during CART.

Risk Factors for Hepatic Hydrothorax in Cirrhosis Patients with Ascites – A Clinical Cohort Study

The risk factors for hepatic hydrothorax are unknown. We used data from three randomized trials of satavaptan treatment in patients with cirrhosis and ascites followed for up to 1year. We excluded patients with previous hepatic hydrothorax or other causes for pleural effusion. The candidate risk factors were age, sex, heart rate, mean arterial pressure, diuretic-resistant ascites, a recurrent need for paracentesis, diabetes, hepatic encephalopathy, International Normalized Ratio, creatinine, bilirubin, albumin, sodium, platelet count, use of non-selective beta-blockers (NSBBs), spironolactone, furosemide, proton pump inhibitors, and insulin. We identified risk factors using a Fine and Gray regression model and backward selection. We reported subdistribution hazard ratios (sHR) for hepatic hydrothorax. Death without hepatic hydrothorax was a competing risk. Our study included 942 patients, of whom 41 developed hepatic hydrothorax and 65 died without having developed it. A recurrent need for paracentesis (sHR: 2.55, 95% CI: 1.28-5.08), bilirubin (sHR: 1.18 per 10µmol/l increase, 95% CI: 1.09-1.28), diabetes (sHR: 2.49, 95% CI: 1.30-4.77) and non-use of non-selective beta-blockers (sHR: 2.27, 95% CI: 1.13-4.53) were risk factors for hepatic hydrothorax. Development of hepatic hydrothorax was associated with a high mortality-hazard ratio of 4.35 (95% CI: 2.76-6.97). In patients with cirrhosis and ascites, risk factors for hepatic hydrothorax were a recurrent need for paracentesis, a high bilirubin, diabetes and non-use of NSBBs. Among these patients with cirrhosis and ascites, development of hepatic hydrothorax increased mortality fourfold.

Assessment of hemodynamic parameters of hepatic and visceral blood flow in decompensated liver cirrhosis

The aim. To assess the hemodynamic parameters of the hepatic and visceral blood flow in patients with compensated and decompensated liver cirrhosis. Materials and methods. 290 patients with liver cirrhosis were examined: 206 had gastrointestinal bleeding, 84 had diuretic-resistant ascites. Ultrasonic scanning, Doppler sonography, esophagogastroduodenoscopy, angiography, radioisotope scintigraphy were performed to assess blood flow in the portal, splenic and superior mesenteric veins and in the hepatic, splenic and superior mesenteric arteries. Results. Change in the hepatic microcirculatory blood flow in the natural course of liver cirrhosis was characterized by decreased portal and increased arterial blood flow, “arterialization” of hepatic blood flow based on scintigraphy. Decompensation of the disease was associated with progressive reduction in both portal and arterial hepatic blood flow, which were correlated with the severity of functional liver disorders regardless of the complication nature. The portal blood flow in the natural course of liver cirrhosis was characterized by 3.5–4.5 times increased volume of visceral blood. Decompensation of the disease was accompanied by a decrease in blood flow in the portal vein as compared to the splenic and superior mesenteric veins by 1.8–2.2 and 1.5–2.7 times, respectively. Arterial blood flow in the natural course of liver cirrhosis was characterized by a relatively increased hepatic arterial flow. The ultrasound criterion of hepatic blood flow “arterialization” was an increase in hepatic-splenic arterial index, which can be used as a sign to differentiate between different forms of portal hypertension. Decompensation of the disease was characterized by an average of 8.2 % decreased arterial blood flow in the hepatic artery compared to the splenic artery in dynamics. Prognostically unfavorable signs were the progression of splenomegaly degree, the increase in the portal vein diameter with the decreased velocity characterizing the increase in congestive index by 2.4–2.6 times, the decrease in the hepatic artery diameter and velocity in it over time.Conclusions. The hepatic and visceral blood flow characteristics should be considered when choosing method of conservative, surgical or minimally invasive treatment of liver cirrhosis complications. Based on the hepatic hemodynamic characteristics, the mismatch between portal perfusion (reduced) and visceral blood flow (increased) is the essence of portal hypertension in liver cirrhosis. Accordingly, the criterion of treatment effectiveness in decompensated liver cirrhosis should be improved portal liver perfusion and (or) reduced volume of visceral blood flow.

Transjugular intrahepatic portosystemic shunting in combined treatment of a patient with decompensated liver cirrhosis and malignant neoplasm of the uterus (clinical case)

Nowadays the treatment of patients with malignant neoplasms of the abdominal organs against the background of decompensated liver cirrhosis is largely an unsolved problem. Complications of portal hypertension syndrome such as ascites, hypersplenism, recurrent bleeding from the veins of the esophagus prevent the implementation of radical surgical treatment. Low trauma of endovascular methods of treatment, low level of complications and mortality are the main advantages of interventional techniques that make it possible to prepare a patient with portal hypertension syndrome for further radical treatment of oncological disease. The presented clinical case describes the results of a combined approach to the treatment of a patient with complications of portal hypertension syndrome and a competing disease a giant tumor of the uterus. The patient was denied in surgical treatment for the neoplasm due to the presence of decompensated cirrhosis. Liver transplantation is not possible due to the presence of cancer. Transjugular intrahepatic portosystemic shunting led to relief of diuretic-resistant ascites, regression of the degree of esophageal varicose veins, which made it possible to remove the tumor with extirpation of the uterus with appendages. Up to now the observation period for the patient is more than 12 years (4 figs, bibliography: 7 refs).

2224 A Rare Complication of Post-TIPS Related Acute Cholecystitis

INTRODUCTION: Amongst the well documented TIPS-related biliary complications, there has been no reported case of acute cholecystitis. Multiple multicenter RCT comparing TIPS to large volume paracentesis reported better control of ascites, lower diuretic doses or cessation of diuretics in approximately 75% of the patients. Biliary related complications include biliary venous fistulas, biloma or biliary occlusion secondary to biliary compression. This may be the first reported case of Post TIPS acute cholecystitis. CASE DESCRIPTION/METHODS: 67-year-old white male with end-stage NASH cirrhosis was hospitalized 6 months ago for diuretic-resistant ascites. Prior to admission, he has required weekly large volume paracentesis. While hospitalized, he underwent large-volume paracentesis and was treated for acute urinary tract infection. TIPS was placed two weeks post discharged and ascites improved. Three days later while undergoing further evaluation, a liver ultrasound showed gall bladder wall thickening and gall stones, suggestive of acute cholecystitis with cholelithiasis. He subsequently developed severe pancytopenia and worsening liver function test. A percutaneous cholecystostomy tube was placed for gall bladder decompression along with a 14-day course of IV antibiotics. He later developed Choledocholithiasis and required ERCP and cholangioscopy. Multiple stones were extracted from the bile duct and complete fibrosis of the cystic duct was noted. The patient required multiple hospitalizations since then, frequent paracentesis and treatment for SBP. He recently underwent OLT with cholecystectomy which was technically challenging. DISCUSSION: TIPS insertion has been established as an effective second-line treatment for refractory ascites. There are 3 documented category of TIPS complications; technical, portosystemic and unique shunt related but no known reported case of acute cholecystitis. Hepatic encephalopathy occurs in approximately 30% of patients, early thrombosis or delayed shunt stenosis occurred in 22- 50% of patients prior to the development of polytetrafluoroethylene-covered stents. The technical intricacy of this intervention poses a potential risk, and morbidity rates as high as 20%. A broad understanding of the uncommon and unique complications can potentially decrease post-op-related complications especially in a patient undergoing OLT It is necessary for clinicians who perform this procedure to be aware of the clinical spectrum of TIPS-related complications and their management.

Preoperative Mac-2 binding protein glycosylation isomer level predicts postoperative ascites in patients with hepatic resection for hepatocellular carcinoma.

Postoperative ascites is one of the most common complications after hepatic resection and is related to liver fibrosis. Mac-2 binding protein glycosylation isomer (M2BPGi) is a reliable and non-invasive marker for assessing liver fibrosis. This study aimed to evaluate whether preoperative M2BPGi level can predict postoperative refractory ascites in patients with curative hepatic resection for hepatocellular carcinoma. The present study retrospectively evaluated 59 patients between January 2016 and June 2018. We assessed the relationship between preoperative M2BPGi levels, expressed as the cut-off index, and postoperative ascites. The median M2BPGi level was 1.36 (range 0.34-11.56). Postoperative ascites occurred in seven patients (11.9%). Among them, refractory ascites, defined as diuretic-resistant ascites, occurred in four patients (6.8%). Uni- and multivariate analysis showed that preoperative M2BPGi level was the only independent risk factor of postoperative ascites (odds ratio 3.28, P = 0.033). The cut-off values of M2BPGi for postoperative ascites and refractory ascites were 2.41 and 3.10, respectively. Remarkably, there were no patients with postoperative ascites and refractory ascites when the preoperative M2BPGi levels were less than each cut-off value. Our results suggest that M2BPGi level is a reliable and non-invasive surrogate marker for predicting postoperative ascites before curative resection for hepatocellular carcinoma.

Study of use of saphenoperitoneal shunts in intractable ascites

Background: Ascites is a common complication in patients with chronic liver disease. Ascites usually complicates chronic liver disease, and some patients with ascites are refractory to medical treatment. Recently, saphenoperitoneal shunt was described to treat this condition. This procedure avoids the insertion of a foreign expensive shunt into the circulation. Describe the experience with this procedure with some changes in the technique.Methods: A prospective study was performed on 8 patients with intractable ascites admitted to the surgical ward of Maharani Laxmi Bai Medical College during the period from November 1999 to April 2001. Eight patients with chronic liver disease and diuretic-resistant ascites underwent this procedure. The patients were classified by severity of liver disease as estimated from serum bilirubin and albumin values. Observations were present in tables, number and percentage using Microsoft excel.Results: Procedure performed in 8 patients and was successful 6 patients. Effective doses of diuretics required were decreased to one eighth of the preoperative dose over a median 3 months post- operative period. No patient with successful shunt needed postoperative paracentesis or re-hospitalization in a median follow-up of 8 month. No other complication was found except ascitic leakage.Conclusions: All patients, who had a successful shunt had symptomatic relief from ascites. Therefore the saphenoperitoneal shunt potentially offers all the benefits of peritoneovenous shunting without the disadvantage of using prosthetic material.

Albumin in Cirrhosis: More Than a Colloid.

Albumin has repeatedly been shown to be beneficial in treating patients with decompensated cirrhosis. We reviewed the medical literature regarding indications for the use of intravenous albumin in cirrhosis, with particular focus on the ways in which albumin can help mitigate hepatorenal physiology. Albumin has long been used as the preferred agent for volume expansion in patients with decompensated cirrhosis. It is used in conjunction with vasoconstrictors for the treatment of type 1 hepatorenal syndrome, and in combination with antibiotics for the treatment of spontaneous bacterial peritonitis. When given at the time of large volume paracentesis, albumin is known to help reduce the incidence of post-paracentesis circulatory dysfunction. Recently, albumin has been shown to improve outcomes in hospitalized patients with cirrhosis and hyponatremia, and has also shown promise in reducing mortality and hospitalizations in outpatients with both diuretic resistant and uncomplicated ascites. It is increasingly clear that these benefits derive from a combination of the oncotic and non-oncotic properties of albumin, and from the effects of albumin administration on effective arterial blood volume. Albumin is an effective treatment for multiple complications encountered in patients with decompensated cirrhosis.

Drowning on Land

Liver cirrhosis affects people worldwide. Its pathophysiology is complex as countless medical illnesses may lead to cirrhosis. Well-known complications from cirrhosis include encephalopathy, ascites, and gastrointestinal bleeding due to esophageal, gastric or rectal varices. A less common complication is hepatic hydrothorax (HH), which is a transudative effusion mostly seen in diuretic resistant ascites. Presence of HH should raise concern as patients may develop respiratory failure and it is associated with higher mortality within one year of diagnosis. This is the case of a 63 year-old-male with past medical history of Arterial Hypertension, Diabetes Mellitus Type II, Dyslipidemia, Obesity, and Chronic Liver Disease with Cirrhosis secondary to NASH who presented to the ER due to progressive shortness of breath and cough with 10 days of evolution. Patient denied chest pain, fever, chills, or other symptoms. Vital signs remarkable for respiratory rate of 21. Physical examination was striking for decrease breath sounds on the left hemithorax, and mild expiratory wheezes. Abdominal examination with minimal distension, soft/ depressible, and no fluid wave. Lower extremities with bilateral pitting edema up to the knee more prominent at the right extremity. Laboratories unremarkable, normal Pro BNP and Troponins. Chest X-ray presented with large left sided pleural effusion. Echocardiogram was unremarkable. Thoracentesis was done with 2400 mL of fluid removed revealing a transudative effusion. A paracentesis was performed with 2800 mL removed. Leveen shunt revealed diffuse radiotracer concentration throughout the left hemithorax suggestive of Left HH. Patient with multiple visits to the ER due to diuretic refractory ascites requiring paracentesis and thoracentesis, reason for which TIPS was recommended. HH is a rare complication of cirrhosis and is infrequent in the left hemithorax. It is imperative to remain conscious of HH in cirrhotic patients who present with shortness of breath with the presence of pleural effusion without cardiac, pneumological or infectious diseases. Diuretics, sodium restricted diet, thoracentesis, and TIPS are among the few treatment options; however, no definite treatment has been established. Liver transplantation should be expedited in these patients due to increased mortality within first year of diagnosis.

Slow, Continuous Low-Dose Albumin and Furosemide Infusion (SCLAFI) With/Without Terlipressin Mobilizes Refractory Ascites Safely in Decompensated Liver Cirrhosis

Background and Aim: Graded increase of oral diuretics has been the standard therapy for mobilizing large ascites in decompensated liver cirrhosis. Large volume paracentesis (LVP) with or without albumin infusions has been the commonest rescue therapy. Both are sought with complications. The study was done to study the efficacy and safety of low-dose, continuous, infusion of furosemide with albumin, administered according to a response-guided protocol in patients with cirrhosis and large ascites. Methods: Cirrhotic patients with refractory ascites (intractable/resistant) who had undergone multiple sessions of large volume paracentesis in past 3 months were enrolled. Furosemide infusion at 2 mg/h and albumin 2 g/h (20 g/d) was started. Blood and urine (electrolytes) samples were collected every 12 h for UNa, UK and graded increase of furosemide was done by 1 mg (max5 mg/h) if UNa < 80 mmol/L. Aggressive potassium supplementation (oral/iv) was done in all patients. If after 48 h UNa was still <80 mmol/l then terlipressin infusion @4 mg/12 h was started after correcting anemia and baseline ECG (repeated 12th hourly) and response guided increase (1 mg/12th hourly) was done (maximum 8 mg/24 h). Patients were shifted to oral diuretics at discharge maintaining UNa >80 mmol/24 h. Results: 70 patients (M:F—50:20) were enrolled from November 2013 and July 2016. 57 patients had diuretic intractable ascites and 13 had diuretic resistant ascites. 19 patients required albumin-furosemide infusion only while 51 required terlipressin infusion also. Ascites responded (clinically dry) to the treatment regimen in all patients over a median period of 7.4 ± 2.5 days. The mean values of the patient were: age 47.2 ± 13.4, CTP 11.68 ± 1.36, MELD 24.5 ± 6.7, creatinine at baseline (bl) 1.42 ± 1.05, creatinine at end of treatment (EOT) 0.94 ± 0.43, serum sodium (SNa) (bl) 129.28 ± 7.5, SNa (EOT) 133.96 ± 5.45, weight loss 14.44 kg, UNa (bl) 17.2 ± 5.86, maximum (max) UNa 171.24 ± 61.35, UNa at discharge 86.4 ± 19.56, serum albumin (bl) 2.5 ± 0.5, urine output (UO) (bl) 642.7 ± 185.3, UO (max) 2972.08 ± 803.6. Conclusion: Closely monitored, response-guided use of frusemide infusion with albumin ± terlipressin is a safe and effective way of treating large ascites reducing the need for LVP (Figure 1 and Table 1).Table 1Patient Characteristics Among Two Groups.ParametersGroup 1SDGroup 2SDPMELD24.046.224.87.70.74CTP11.61.211.71.40.76Creat 11.050.421.380.800.05Creat (D)0.860.341.0140.250.32Na1130.77.48128.67.490.7Na(D)134.095.1132.676.860.4U Na (bl)21.55.3110.293.550.00UNa 48 h87.911.543.910.260.00U Na max186.787.9207121.990.5U Na (D)91.224.5104.2458.50.34MAP184.13.876.73.30.01MAP284.93.484.22.60.38UO (bl)663.03 ml244.03 ml453.3 ml205.80.01UO (Max)3.37 L0.981 L4.2 L1.3 L0.02UO (D)2.1 L1.06 L2.7 L1.49 L0.14Albumin2.40.452.20.460.12INR2.40.72.60.460.22Wt loss13.95.515.44.50.4Duration7.42.510.42.10.06 Open table in a new tab The authors have none to declare.

THU-038 - The effect of planned care on resource use and end of life outcomes in patients with diuretic resistant ascites: a retrospective cohort study of deaths in England

THU-038 - The effect of planned care on resource use and end of life outcomes in patients with diuretic resistant ascites: a retrospective cohort study of deaths in England

Permanent catheter drainage system for palliation of diuretic-resistant cardiac ascites.

We report the case of a 69‐year‐old man with dilated cardiomyopathy treated with a permanent catheter drainage system for diuretic resistant cardiac ascites. At 1 year follow‐up, the patient had no heart failure related hospitalisations, displayed improved quality of life measures and had incurred no complications related to the catheter. Permanent tunnelled catheters are widely used to treat malignant ascites but may also be considered for palliation of cardiac ascites.

Assessment of splanchnic hemodynamics in patients with cirrhosis after splenectomy in comparison with non-operated patients at the decompensated stage

Splenectomy in patients with cirrhosis presupposes an increase of blood inflow into portal system to decrease the portal pressure. At the same time there are different opinions about splenectomy. So it is actual to study the character of changes of blood flow in vessels of abdominal cavity in pre- and postsurgical periods and assessment of an influence of these changes on the clinical course of cirrhosis.Aim of research: To assess an influence of splenectomy on the character of changes of splanchnic hemodynamics in patients with cirrhosis comparing to non-operated patients with compensated and decompensated clinical course.Materials and methods: There were examined 190 patients with cirrhosis: gastrointestinal bleeding from oesophagus varicose veins took place in 133 patients, diuretic resistant ascites – in 57 ones. 19 patients underwent splenectomy: 7 – in association with sewing of the left gastric vein and artery, 6 – with “skeletonization” of the lesser curvature of stomach with Nessen’s operation, 2 – with Patsiora’s operation, 2 – with application of selective porto-caval shunt between the low mesenteric vein and the left vein of an ovary. 84 patients died during observation. The duration of observation was from 0.5 to 3.5 years. All patients underwent fibrogastroscopy every 3–4 month. Hemodynamics was assessed on the base of repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; qualitative and quantitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research: Changes of hemodynamics in patients after splenectomy as opposed to non-operative patients are characterized with the decrease of diameter of portal vein at almost stable speed of the linear blood flow in it. The result is some decrease of the volume of portal blood and index of portal blood congestion that indirectly indicates the decrease of portal pressure after splenectomy. At the same time arterial hepatic blood flow stays without essential changes.At fibrogastroscopy there was noticed a decrease of esophageal varicose veins dilatation, its tension, elimination of «red signs” that is a prognostic marker of the menace of bleeding. There were noticed no one relapse of bleeding and the sign of refractory ascites during the period of observation.Conclusio: The changes of splanchnic hemodynamics after splenectomy are characterized with decrease of the volume of splanchnic blood. The result is a decrease of portal pressure that is proved with decrease of congestion index in portal vein, decrease of tension of varicose veins, elimination of “red signs” and consequently elimination of the menace of relapse of bleeding and development of resistant ascites. At the same time splectomy can be done in patients with decompensated clinical course of cirrhosis that is proved with an absence of lethality in postsurgical period

Assessment of splanchnic hemodynamics in patients with cirrhosis after separating operations in comparison with non-operated patients with compensated and decompensated clinical course

Separating operations are recommended for treatment and prophylaxis of bleeding from varicose veins of gullet as a result of portocaval (azygoportal) shunting at cirrhosis and directed to its elimination using azygoportal separation. At the same time the frequency of relapse of bleeding after operations remains rather high. And the formation of new varicose nodi as a result of disorder of hepatic and splanchnic hemodynamics that inevitably appears at different dates after operation is considered as the main cause of it. At the same time an assessment of hemodynamic changes after azygoportal separation is interpreted in different ways by different authors.Aim of research. To assess an influence of separating surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with non-operated patients with compensated and decompensated clinical course.Material and methods. There were examined 190 patients with cirrhosis: in 133 took place gastrointestinal bleeding from varicose veins of gullet, in 57 – diuretic resistant ascites. 16 patients underwent separating operations. 20 patients underwent endoscopic sclerotherapy of gullet veins. 84 patients died during observation (7 after surgical treatment). Duration of observation was from 2-3 weeks to 2,5-3 years. All patients underwent the repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research. At assessment of splanchnic hemodynamics the changes of portal blood flow in first months after operation characterized with moderate dilation of portal vein and decrease of linear speed in it. At the same time the volumetric blood flow did not essentially change. It was noticed the decrease of volumetric blood flow in splenic vein at the expense of constriction of its lumen and decrease of linear speed in it. Arterial blood flow characterized with decrease of inflow to liver through hepatic artery and increase of blood flow through splenic artery. At later dates the character of changes of splanchnic hemodynamics after azygoportal separation was analogous on all indicators to non-operated patients at transfer from compensated to decompensated course of cirrhosis – decrease of blood flow through the portal vein and hepatic artery at relative increase of splenic blood flow. An increase of index of stagnation in the portal vein and splenic-hepatic portal index that took place in all operated patients and non-operated ones at the stage of decompensation was an unfavorable prognostic indication.Conclusion. The character of changes of splanchnic hemodynamics after gastroesophageal separation is analogous to non-operated patients at transfer from compensated course of cirrhosis to decompensated one. Decrease of the portal blood inflow through the splenic vein is a compensatory mechanism that must decrease the portal pressure. The quality of life in postsurgical period is determined by duration of compensation of hemodynamic disorders

Assessment of splanchnic hemodynamics in patients with cirrhosis after portocaval shunting in comparison with no-operated patients with the compensated and decompensated course of disease

Portocaval shunting is recommended for decrease of the portal pressure and regression of the varicose veins in patients with cirrhosis. But the shunting surgery at cirrhosis is limited by the high risk of development of hepatic encephalopathy and the hepatocellular insufficiency in post-surgical period. And the disorder of the hepatic and splanchnic hemodynamics that inevitably appears at different dates after surgery is considered as the main cause of these states.Aim of research. To assess an influence of the shunting surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with no-operated patients with compensated and decompensated course of disease.Material and methods. 190 patients with cirrhosis were examined: 133 had gastrointestinal bleeding, 57 – diuretic-resistant ascites. 18 patients underwent surgery – portocaval shunting. 84 patients died during observation (10 after surgery). The duration of observation was from 2-3 weeks to 2,5-3 years.All patients underwent the repeated ultrasound examination of abdominal cavity. There were defined the diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of the blood flow in hepatic and splenic arteries, in portal and splenic veins. Results of research. At assessment of splanchnic hemodynamics we noticed the differences of parameters depending on time that passed after surgery. The changes of portal blood flow in first 3-6 month were characterized by the moderate widening of portal and splenic veins at little decrease of its mean linear and volume speed so an inflow of the portal blood still stable. Arterial blood flow in hepatic artery was forced at the expense of both widening of diameter and increase of the mean speed of blood flow. The splenic arterial blood flow practically was not changed. The reliable decrease of the volume blood flow in portal vein at the expense of decrease of its linear speed was observed in all patients at later dates. An unfavorable sign was an increase of an index of haemostasia in portal vein and of splenic and hepatic portal index in dynamics that took place in all operated patients and in no-operated ones at the stage of decompensation.Conclusions. The character of changes of splanchnic hemodynamics after portocaval shunting is analogous to the one in no-operated patients at transition from the compensated course of cirrhosis to decompensated one. The compensatory mechanism that preserves the volume of the portal inflow to liver is the widening of the portal vein and preservation of the splenic blood flow. The quality of life in post-surgical period is determined by the duration of compensation of hemodynamic disorders