Treatment for cirrhotic ascites

Common complications of decompensated liver cirrhosis are esophageal varices, hepatic encephalopathy and ascites. After the onset of complications, the prognosis worsens. In patients with ascites, the 5‐year mortality rate is 44%. Furthermore, hyponatremia, spontaneous bacterial translocation and hepatorenal syndrome also greatly worsen the prognosis. Effective treatment of cirrhotic ascites improves the quality of life and survival rate. Recently, the newly produced diuretic, tolvaptan (vasopressin V2 receptor antagonist), was reported to be effective in the treatment of refractory ascites in liver cirrhosis; however, there has not been an associated positive effect on the prognosis. There are various types of treatment for ascites, such as large‐volume paracenteses, a cell‐free and concentrated ascites reinfusion therapy, a transjugular intrahepatic portosystemic shunt, and a peritoneo‐venous shunt. Although they improve the prognosis, liver transplantation remains the ultimate form of treatment. The present article discusses the therapeutic management of cirrhotic ascites.     

Treatment of cirrhotic ascites by dialytic ultrafiltration with a hemofilter system

Dialytic ultrafiltration with a hemofilter was performed in 21 cirrhotic patients with intractable ascites refractory to sodium restriction and diuretic therapy. A continuous flow of ascitic fluid at a rate of 300-400 ml/min through a hemofilter was maintained by the use of a single-head blood pump. The protein-rich ascitic fluid was reinfused into the peritoneal cavity, whereas sodium and water were filtered and removed. An average of 6.8 liters of filtrate was removed over an averaged period of 4.4 h. The new technique is simple, safe, and cost-effective as compared with conventional treatment of paracentesis. Rapid relief of symptom related to intractable ascites could readily be achieved. These patients remained hemodynamically stable, and no major complications such as hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding were experienced.     

Spontaneous peritonitis in cirrhotic ascites

In a ten-year retrospective study 15 cases of spontaneous bacterial peritonitis were identified. All patients had cirrhosis and ascites. Abdominal pain was present in all and abdominal tenderness in 11. Diagnosis was established by paracentesis with the finding of either an elevated ascitic fluid cell count (>300 WBC/mm³) in 13 cases or organisms and numerous neutrophiles on gram stain in 6 cases. On ascitic fluid cultureE coli was the most common organism isolated in 6 cases, klebsiella was isolated in 3 cases, andDiplococcus pneumoniae (D. pneumoniae) in 2 cases. Positive blood cultures were obtained in 60% of the cases. Three patients responded to therapy, including antibiotics, and survived to leave the hospital. No features unequivocally differentiated the survivors. The nonsurvivors died from complications of advanced liver disease including hepatic coma, hepatorenal syndrome, and esophageal variceal hemorrhage. Spontaneous bacterial peritonitis is a potentially treatable cause of deterioration in the patient with cirrhotic ascites. Because of its varied presentation it may escape recognition despite ease of diagnosis. Prompt recognition requires awareness of this entity.     

肝硬化腹水的诊断及鉴别诊断

正常腹腔内有少量液体,通常在100-200 m1以内。肝硬化腹水大多隐匿出现,也可突然发生。少量腹水无明显症状和体征,当     

Propranolol in the treatment of cirrhotic ascites

Propranolol hydrochloride is reported to lower portal pressure and inhibit renin secretion in patients with chronic liver disease, actions that might lessen the tendency to ascites formation. We compared the effect of diuretics with that of the same dose of diuretics plus propranolol on natriuresis, urine output, and daily weight loss in 13 hospitalized patients with stable chronic liver disease, sodium retention, and ascites. The propranolol hydrochloride dose was 20 to 160 mg four times a day, titrated to reduce resting pulse by 25% or systolic BP 10 mm Hg. Diuretics given were furosemide, 80 to 160 mg, and triamterene, 100 or 200 mg/day. Periods of time when each regimen was received ranged from one to four days. Creatinine excretion documented complete urine collections. Compared with diuretics alone, diuretics plus propranolol substantially reduced resting pulse, systolic BP, and urine sodium excretion, although not creatinine clearance. This antinatriuretic effect may limit the proposed usefulness of propranolol for prevention of variceal bleeding in patients with cirrhosis and ascites.     

肝硬化腹水诊治争议问题

腹水是肝硬化预后不良的重要指标。近年来尽管出台了很多有关肝硬化腹水的指南和共识,但其处理中仍存在一些争议。回顾了目前肝硬化腹水处置中的难点及争议问题,如补钠和限钠的时机、利尿剂的选择、利水剂的应用价值、大量放腹水后补充白蛋白的方案、经颈静脉肝内门体分流术的指征和疗效等;并指出运用循证医学手段解决上述争议性问题,有助于提高肝硬化腹水的诊疗水平,改善患者预后。     

肝硬化腹水治疗的新进展

腹水是肝硬化最常见并发症之一,预防和控制腹水的发生和发展是改善肝硬化患者预后的关键。就近几年腹水治疗的新进展进行总结与讨论,主要包括病因治疗、限钠摄入、利尿剂治疗等一线治疗方法的更新,以及对于顽固性腹水治疗的新探索。     

重视肝硬化腹水的临床研究

腹水，影响患者的生活质量，而且影响存活时间。特别是难治性腹水或自发性腹膜炎患者预后更差。因此，对肝硬化腹水发生机制和诊治的研究是值得重视的临床课题。     

The pathophysiologic basis for the treatment of cirrhotic ascites

Advances in the understanding of the pathophysiology of sodium retention and ascites formation in cirrhosis has helped improve the treatment of ascites in these patients. It is likely that further unraveling of these pathophysiologic changes will lead to the development of novel and better treatment options. For example, the development of aquaretic agents for the management of hyponatremia in cirrhosis may allow more effective use of diuretic therapy. The ultimate challenge is to use the understanding of the pathophysiology to develop new strategies to prevent the development of ascites in cirrhosis.     

腹水超滤浓缩回输腹腔治疗肝硬化顽固性腹水疗效评价

目的 评估腹水超滤浓缩回输腹腔术治疗肝炎肝硬化顽固性腹水患者临床疗效。方法75例肝硬化顽固性腹水患者分为治疗组（50例）和对照组（25例）,两组患者均采用保肝、利尿、对症、支持等常规治疗,疗程4周。对照组在常规治疗基础上,采用多次治疗性腹穿放液治疗;治疗组在常规治疗基础上,采用腹水超滤浓缩回输腹腔治疗,观察并比较两组治疗后体重、腹围、24h尿量和尿钠排出量、肝功能、肾功能、血电解质及不良反应。结果治疗4周后治疗组腹围、体重、24h尿量优于对照组（P〈0．01）;血清白蛋白、肾小球滤过率及24h尿钠量高于对照组（P〈0．01）,肌酐、胱抑素c水平低于对照组（P〈0．05。P〈0．01）;治疗组显效率（48．0％）和总有效率（80．0％）明显好于对照组（24．0％和52．0％）（P〈0．05）：两组均未出现严重不良反应。结论腹水超滤浓缩回输腹腔术治疗肝硬化顽固性腹水患者临床疗效优于多次治疗性腹穿放液。