Management of ascites involves sodium and water restriction followed by spironolactone, loop diuretics, and frequent abdominal paracentesis.
Recall the classification of liver disease. Child's Classification is divided into class A, B, and C. In class A, patients have no ascites, bilirubin < 2, no encephalopathy, excellent nutritional status, and albumin > 3.5. In class B, patients have controlled ascites, bilirubins 2-2.5, minimal encephalopathy, good nutritional status, and albumin 3-3.5. Finally, in class C, patients have uncontrolled ascites, bilirubins > 3, severe encephalopathy, poor nutritional status, and albumins < 3. These patients often require transplant.
Starr and Raines discuss diagnosis, management, and prevention of cirrhosis. Alcohol abuse and viral hepatitis are the most common causes although nonalcoholic fatty liver disease is an important emerging cause. Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every 6-12 months. Causes of hepatic encephalopathy include constipation, infection, gastrointestinal bleeding, and electrolyte imbalances.
Hsu and Huang discuss the management of ascites in patients with liver cirrhosis. Ascites occurs in patients with cirrhosis or portal hypertension where hyperdynamic circulatory dysfunction and retention of sodium and water are associated with the activation of the sympathetic and renin-angiotension-aldosterone systems. Complications seen in conjunction with ascites include spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic hydrothorax.
Illustration A depicts transjuglar intrahepatic portosystemic shunt (TIPS) which allows for a bypass of the cirrhotic liver, connecting the portal and caval systems.
Answer 1: Nadalol may be used in prophylaxis of esophageal varacies but would not be indicated in the control of this patient's ascites.
Answer 2: Hydrocholorothiazide is a first line agent for essential hypertension but is not used for ascites.
Answer 4: Acetazolamide is a carbonic anhydrase inhibitor which may be used for hypertension but is not indicated for ascites.
Answer 5: TIPS can be used as a bridge to liver transplant but would not be indicated in a patient with Child's class A or B cirrhosis who had not already tried medical management of his ascites.
Starr SP, Raines D. Cirrhosis: diagnosis, management, and prevention. Am Fam Physician. 2011 Dec 15;84(12):1353-9.
PMID:22230269 (Link to Abstract)
Hsu SJ, Huang HC. Management of ascites in patients with liver cirrhosis: recent evidence and controversies. J Chin Med Assoc. 2013 Mar;76(3):123-30. doi: 10.1016/j.jcma.2012.11.005. Epub 2013 Jan 23.
PMID:23497963 (Link to Abstract)