The following statement(s) is/are true concerning the management of ascites associated with chronic liver disease.
- Spontaneous bacterial peritonitis is an insignificant complication
- Large volume paracentesis is unsafe due to excessive volume loss from the intervascular space
- Peritoneovenous shunting is a trivial surgical procedure with minimal perioperative morbidity and mortality
- Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy
d. Transjugular intrahepatic portosystemic shunts (TIPS) can effectively treat ascites in patients refractory to conventional medical therapy
The onset of ascites usually indicates the presence of advanced liver disease. Cirrhotic ascites is usually straw colored, clear, or greenish. Spontaneous bacterial peritonitis occurs as a complication of cirrhotic ascites in up to 10% of patients. Spontaneous bacterial peritonitis is defined as infected ascitic fluid without a demonstrable other site of infection. This is a serious complication with reported in-hospital mortality rates of 60% to 90%. The rational approach of therapy for ascites includes sodium and fluid restriction, the use of diuretics, and the use of therapeutic paracentesis. Several studies have shown that repeated paracentesis in stable cirrhotic patients may be safe and effective as medical therapy and shortens the length of hospitalization. Single, large volume paracentesis has been reported to be effective and safe. Up to 10 liters of ascites can be removed in one hour if salt-poor albumen is administered simultaneously. In a small percentage of patients, surgical implantation of a peritoneovenous shunt may be advisable. The principal indication for use of peritoneovenous shunt is to stabilize ascites that is refractory to conventional medical therapy and therapeutic paracentesis. Despite the simplistic nature of the device, postoperative mortality and morbidity rates of 20% to 60%, respectively have been reported. Precipitation of disseminated intravascular coagulopathy, variceal hemorrhage, or hepatic failure may complicate this procedure. Transintrahepatic portosystemic shunts (TIPS) have been demonstrated to control ascites in one study in over 90% of patients with ascites refractory to medical management. However, patients with poor hepatic reserve in this study all died if orthotopic liver transplantation was not performed. This data suggests that TIPS is effective for refractive ascites in patients with good to moderate hepatic reserve but poor risk cirrhotics require orthotopic liver transplantation to correct this problem.
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