Prise en charge symptomatique de l’ascite maligne en phase palliative: place de la paracentèse et des diurétiques. Supportive care for malignant ascites in. Chez dix patients cirrhotiques porteurs d’une ascite sous tension, la pression voie endoscopique au moyen d’une fine aiguille, avant et après paracentèse. Mr G. presented for acute care 3 weeks ago with tense ascites, which was managed with a large volume paracentesis (LVP) of approximately 4 L. He was.
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He is married and has 3 adult children. He is being seen today at home because of a rapid decline in function and escalation of symptoms. His overall appetite has declined, and this is paracfntese to his family.
His paraventese bowel movement was 3 days ago. On examination, Mr G. Findings from his cardiopulmonary examination are unremarkable. His abdomen is markedly distended with no pain on palpation or rebound tenderness, and testing for shifting dullness reveals positive results of fluid shift.
He also has moderate bilateral peripheral edema. Goals and direction of care are discussed with Mr G.
Ascites in patients with cirrhosis
Cirrhosis is characterized by diffuse fibrosis of liver parenchyma resulting in structurally abnormal liver nodules. In North America, cirrhosis has become the eighth leading cause of death, 1 with alcoholic liver disease, hepatitis C, and nonalcoholic fatty liver disease as the 3 main causes. The natural history of cirrhotic liver disease progresses from a compensated to a decompensated phase.
Ascites is the main complication of cirrhosis, 3 and the mean time period to its development is approximately 10 years. Ascites is defined as the presence of excessive fluid in the peritoneal cavity. Fundamental to the formation of ascites in cirrhosis are portal hypertension, which causes splanchnic vasodilation, and activation of the renin-angiotensin-aldosterone system, further resulting in renal sodium retention.
At end-stage cirrhosis, ascites causes symptoms including abdominal distention, nausea and vomiting, early satiety, dyspnea, lower-extremity edema, and reduced mobility. Clinically, on investigation of a full, bulging abdomen, percussion of the flanks and checking for shifting dullness can detect ascites.
Radiographically, an abdominal ultrasound is useful in defining the extent of ascites in new-onset or worsening ascites. Abdominal paracentesis, ascitic fluid analysis, and the use of the serum ascites albumin gradient are the most rapid and cost-effective methods of diagnosing the cause of ascites and directing management.
Decision making on the management of ascites depends on the severity of symptoms and not the presence of ascites in and of itself. The medical management of ascites includes sodium restriction and use of diuretics. First-line therapy includes sodium restriction.
Paracentesis – Wikipedia
Second-line therapy includes the use of pparacentese. Spironolactone is considered the first-line diuretic because aldosterone is the main factor responsible for renal sodium retention in cirrhosis.
Common side effects of furosemide include the following: A common decision-making point is whether to start diuretics as monotherapy or as combined therapy. Studies have shown that spironolactone monotherapy and combination therapy with spironolactone and furosemide are equally effective at relieving ascites.
If more rapid symptom control is required, or if the patient has recurrent ascites, then starting combination therapy from the onset should be considered. Once ascitic fluid is mobilized and symptom control is achieved, the dosage of diuretics needs to be reconsidered with the goal of maintaining symptom control with the lowest dose of diuretics possible in order to prevent diuretic-induced side effects. Refractory ascites occurs in patients who do not respond to diuretic therapy, who have diuretic-induced complications, or for whom ascites recurs rapidly after therapeutic paracentesis.
As LVP does not treat the underlying cause of ascites, salt restriction and diuretic therapy to slow down the rate of reaccumulation should be continued.
Ascites in patients with cirrhosis
The decision whether to continue serial therapeutic paracentesis versus considering a permanent indwelling catheter is guided by the patient and his or her burden of disease, prognosis, and goals of care. Indwelling catheters, such as a pigtail catheter or a pleural catheter, are an option for those patients who require frequent paracenteses. Tunneled catheters are preferred over pigtail catheters owing to stability and lower rates of infection.
Permanent catheters can be under continuous or intermittent drainage, with the frequency determined by the patient in accordance with symptom control. What the exact risk of infection posed by an indwelling catheter is and whether or not patients require prophylactic antibiotics is not well defined in the literature.
A TIPS is a shunt between the portal vein and the hepatic vein, designed to reduce portal hypertension and improve renal sodium excretion by directly bypassing the cirrhotic parenchymal tissue. He is given an enema with good results, and then starts taking 2 senna tablets orally once daily at bedtime. Within 7 days, Mr G.
He agrees to have a permanent indwelling catheter inserted. Every 1 to 2 days, Mr G.
Despite this, Mr G. A mg oral dose of metoclopramide is started 3 times daily before meals and a fourth ascife at bedtime. He is no longer able to swallow his medications including his diuretics.
Management of patients with ascites in end-stage cirrhosis is becoming more common in palliative care. The series explores common situations experienced by family physicians doing palliative care as part of their primary care practice. Please send any ideas for future articles to ac. National Center for Biotechnology InformationU. Journal List Can Fam Physician v. Author information Copyright and License information Disclaimer.
This article has been cited by other articles in PMC. Definition, features, and investigation Ascites is defined as the presence of excessive fluid in the peritoneal cavity. Medical management Decision making on the management of ascites depends on the severity of symptoms and not the presence of ascites in and of itself. Sodium restriction First-line therapy includes sodium restriction. Diuretics Second-line therapy includes the use of diuretics. Management of refractory ascites Refractory ascites occurs in patients who do not respond to diuretic therapy, who have diuretic-induced complications, or for whom ascites recurs rapidly after therapeutic paracentesis.
Indwelling peritoneal catheters The decision whether to continue serial therapeutic paracentesis versus considering a permanent indwelling catheter is guided by the patient and his or her burden of disease, prognosis, and goals of care. Transjugular intrahepatic portosystemic shunt A TIPS is a shunt between the portal vein and the hepatic vein, designed to reduce portal hypertension and improve renal sodium excretion by directly bypassing the cirrhotic parenchymal tissue.
Back to the case Mr G. Conclusion Management of patients with ascites in end-stage cirrhosis is becoming more common in palliative care. Management of ascites includes sodium restriction and use of diuretics. Large volume paracentesis, indwelling peritoneal catheters, or transjugular intrahepatic portosystemic shunts can be considered in refractory ascites.
Competing interests None declared. Heidelbaugh JJ, Sherbondy M. Cirrhosis and chronic liver failure: European Association for the Study of the Liver EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Epub Jun 1. Natural history and prognostic indicators of survival in cirrhosis: Epub Nov 9. Portal hypertension and ascites. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites.
Management of ascites in cirrhosis. Current management of the complications of portal hypertension: Management of refractory ascites. Diagnosis and management of delayed hemoperitoneum following therapeutic paracentesis. Proc Bayl Univ Med Cent ; 26 2: Int J Clin Oncol.
Epub Mar Prospective evaluation of the PleurX catheter when used to treat recurrent ascites associated with malignancy. J Vasc Interv Radiol. Epub Oct Transjugular intrahepatic portosystemic shunt in refractory ascites: Transjugular intrahepatic portosystemic shunt for refractory ascites: Epub Jun Incidence, natural history, and risk asxite of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts.