Introduction:
The liver has many vital functions, including filtering the blood, removing the toxins, making protein for blood clotting, producing bile that digests fats, and metabolizing the drugs. Cirrhosis of the liver is still one of the leading causes of death. Most often, it is asymptomatic, eventually resulting in liver failure. Only one-third of the diseased population know that they have cirrhosis. Recent studies reveal that the fibrosis of the liver is a continuous process, and early cirrhosis could be reversible.
What Is Cirrhosis of the Liver?
Cirrhosis is the scarring of the tissues of the liver due to long-term damage to the liver. The scar tissue replaces the healthy liver cells and prevents proper blood flow, thus preventing them from performing their normal functions. Once the liver function is affected, they start showing symptoms, and this stage is known as decompensated cirrhosis. It only happens over a long period with an average of ten years. The scarring is irreversible, once cirrhosis is established, we need to evaluate if it is compensated or decompensated. In compensated cirrhosis, the patient is asymptomatic. It is crucial for deciding the prognosis and treatment options in a particular patient.
What Are Ascites?
Ascites is the abnormal buildup of fluids in the abdomen, and it is one of the significant complications of liver cirrhosis associated with a poor prognosis. The blood flow through the liver becomes slow, like in the case of cirrhosis, and the hydrostatic pressure increases in the vein leading to the development of portal hypertension. The continuous renal sodium, water retention, and lymph leakage result in ascites. We should distinguish between cirrhotic and non-cirrhotic causes of ascites for proper treatment.
What Are the Causes of Ascites?
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Cirrhosis related (a serious disease of the liver, caused especially by drinking too much alcohol).
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Congestive heart or kidney failure.
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Chronic infection like hepatitis C or B.
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Clots in the veins of the liver.
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Pericarditis.
How to Diagnose Ascites Related to Cirrhosis?
The symptoms associated with ascites often vary according to the quantity of fluid in the abdominal cavity. If only a minimal amount of fluid is present, the patient might be asymptomatic. The fluid is usually detected on a physical or radiological examination. In case of a large amount of fluid, the patients may experience abdominal fullness, early satiety, pain in the abdomen, and shortness of breath. Diagnosis should be made based on:
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Physical examination - to look for abdominal distention, bulging flanks, shifting dullness, and elicit a ‘puddle sign.’ It is usually challenging to diagnose an obese individual.
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Radiological examination - can detect as low as 30 mL of fluid which is difficult in a physical examination. An abdominal ultrasound or a CT (computed tomography) scan can be helpful. Ultrasound with a doppler can help assess whether the hepatic vessels are obstructed or not.
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Abdominal paracentesis and ascitic fluid analysis - If a noncirrhotic patient develops ascites, diagnostic paracentesis and ascites fluid analysis may be essential. In a cirrhotic patient, it is done in the case of unexplained fever, abdominal pain, or encephalopathy. In an uncomplicated cirrhotic patient, the ascitic fluid appears translucent and yellow. Turbidity and cloudiness of the fluid suggest infection. Milky fluid, commonly known as chylous ascites, is due to thoracic duct injury, lymphoma related to cirrhosis. If an infection is suspected, we should also look for cell count (differential), albumin, and ascitic fluid culture. It is also helpful in determining whether the patient is likely to develop spontaneous bacterial peritonitis (SBP). Sometimes, checking for lactose dehydrogenase levels, glucose, amylase, triglyceride, bilirubin levels can also be helpful.
- Serum ascites albumin gradient (SAAG) to evaluate the presence of portal hypertension. It is determined by subtracting the ascites albumin value from a serum albumin value obtained on the same day. The presence of a gradient higher than 1.1 g/dL suggests that the patient has portal hypertension-related ascites. If it is less than 1.1g/dL, there might be some other cause of ascites that needs to be determined.
What Are the Treatments Available?
Successful treatment of an individual with cirrhotic ascites will aim at reducing the intraperitoneal fluid without affecting the intravascular volume. Minimizing the ascitic liquid can improve abdominal discomfort and dyspnea and lessen the chances of infection-related morbidity. In general, all patients with cirrhosis should be encouraged to reduce alcohol consumption, NSAIDs (nonsteroidal anti-inflammatory drugs), and use of dietary sodium.
Patients are advised to take less than 2000 mg of sodium daily, which in the case of refractory ascites should be reduced to 500 mg. More advanced therapies like the use of oral diuretics, therapeutic paracentesis, placement of transjugular portosystemic shunt (TIPS) in patients with preserved liver function, and liver transplantation depend upon the individual patients.
Medical Management:
A patient with moderate volume ascites shows good improvement by adding low-dose oral diuretics. The first line of therapy includes the combined use of Spironolactone and Furosemide. The response to diuretics must be carefully monitored to assess any changes in weight, serum potassium, blood urea nitrogen (BUN), and creatinine levels. When a patient shows a weight loss of more than 0.5 kg in the absence of edema or more than 1 kg in the presence of edema, hyponatremia, hyperkalemia, renal insufficiency, dehydration, or encephalopathy, diuretics should be reduced or stopped immediately.
What Are the Complications?
Ascites worsen due to excess fluid or salt intake, malignancy, venous occlusion, progressive liver disease, and spontaneous bacterial peritonitis. Other complications include hernias, pleural effusions due to the moving of ascitic fluid across the channels in the diaphragm, HRS-hepatorenal syndrome (unidentifiable cause of renal failure in individuals with advanced liver disease). SBP is diagnosed by an ascitic neutrophil count greater than 250 cells per cubic millimeter. It is treated with the help of antibiotics. Later, they require antibiotic prophylaxis after the first episode of SBP.
What Are Refractory Ascites?
Refractory ascites happen in a patient who does not respond well to high-dose diuretic therapy. Recurrent ascites reduce the survival rate to 50% in a year. Management includes large-volume paracentesis (LVP), placing an indwelling peritoneal catheter, TIPS placement, and liver transplantation.
Conclusion:
The treatment of individuals with end-stage cirrhotic ascites will always aim at providing palliative care. Liver transplantation should be considered for these patients. People must be made aware of alcohol abuse and encouraged to follow a well-balanced, low-fat diet.
