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Clinical management of ascites and complications of liver cirrhosis

Ascites is a known complication of portal hypertension related to decompensated cirrhosis . Albumin has been proposed as a way of addressing the need in therapeutic management , together with other complications of liver cirrhosis
Irsan Hasan Maria Satya Paramitha Department of Internal Medicine , Hepatobiliary Division , Dr Cipto Mangunkusumo National General Hospital , Universitas Indonesia , Jakarta , Indonesia
As a form of end-stage liver fibrosis , liver cirrhosis is the most common cause of liver-related morbidity and mortality worldwide . An analysis conducted by the Global Burden of Disease Study in 195 countries and territories estimated 1.32 million deaths due to cirrhosis in 2017 . 1 There was also an increasing trend of deaths in 2017 ( 2.4 %) compared with 1990 ( 1.9 %). This study also showed lower age-standardised death rate in regions with higher income , with the highest age- standardised death rate in Central Asia . In addition , 36 % of all cirrhosis deaths in Central Asia were attributed to alcohol consumption , whereas hepatitis C and hepatitis B aetiologies were more prevalent in sub-Saharan Africa . In 2017 , the Southeast Asia region had the fifth highest age-standardised death rates among all regions , globally , which was mainly attributed to viral hepatitis . 1
Unfortunately , there has always been an underestimation of the reports of compensated cirrhosis , due to non-specific clinical manifestations at the earlier stages ; thus , leading to the possibility of under-reporting . By contrast , when ascites , hepatic encephalopathy , elevated serum bilirubin level , and acute variceal bleeding occur , increased medical attention is shifted to the patients , resulting in higher accuracy in reporting decompensated cirrhosis . In reality , the case fatality
TABLE 1
Classification and therapeutic options of ascites 3 , 4
Classification Definitions Therapeutic options
Grade 1 ( mild ascites ) Can only be detected through ultrasound examination No specific treatment needed
Grade 2 ( moderate ascites )
Moderate symmetrical abdominal distension
Sodium restriction
Diuretics
Grade 3 ( large / gross ascites )
Significant abdominal distension
Large volume paracentesis ( LVP ) followed by intravenous albumin administration ( 8g / l of ascitic fluid removed ). Subsequently , sodium restriction and diuretics administration are also recommended
Refractory ascites
At least one week of intensive diuretic treatment ( spironolactone 400mg / day and furosemide 160mg / day ) and dietary sodium restrictions (< 90mmol / day ). Lower urinary sodium output compared with sodium intake and mean weight loss of less than 0.8kg in four days . Recurrence of grade 2 or grade 3 ascites within four weeks of initial therapy . The presence of diuretic-induced complications ( e . g . diuretic-induced hepatic encephalopathy , diuretic-induced renal impairment , diuretic-induced hyponatraemia , diuretic-induced hypokalaemia or hyperkalaemia , adverse muscle cramps )
Repeated LVP followed by intravenous albumin administration ( 8g / l of ascitic fluid removed ). If the patient cannot be considered as a good candidate for paracentesis ( e . g . loculated ascites ), consider insertion of transjugular intrahepatic portosystemic shunt
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