ABSTRACT
Ascites and dilutional hyponatremia are frequent conditions in cirrhotic patients and its occurrence has a worse prognosis. Thus, patients with ascites should generally be considered for referral for liver transplantation. The present article explores issues related with ascites classification and the treatment corresponding to each of the 3 degrees of ascites. Regarding refractory ascites, recommendations are included on the use of diuretics, large volume paracentesis with the administration of intravenous albumin and use of transjugular intrahepatic portosystemic shunt (TIPS). Finally, physiopathological aspects involved in the development of dilutional hyponatremia and vaptans treatment, are presented, which are aquaretics that selectively blockade vasopressin V2 receptors in the principal cells of the collecting ducts, being one of the most innovative pharmacological interventions for the management of hyponatremia in cirrhotic patients, in the recent years.
La ascitis e hiponatremia dilucional son complicaciones frecuentes en pacientes con cirrosis avanzada y su aparición implica un peor pronóstico. Por ello, los pacientes con ascitis deberían ser referidos para trasplante hepático. El presente artículo explora los aspectos relacionados con la clasificación de la ascitis y el tratamiento correspondiente a cada uno de los 3 grados de ascitis. En relación al manejo de la ascitis refractaria, se incluyen recomendaciones respecto a la eficacia del uso de diuréticos, paracentesis evacuadora radical con reposición de albúmina intravenosa y uso de cortocircuito porto-sistémico intrahepático (TIPS). Finalmente, se abordan los aspectos fisiopatológicos involucrados en el desarrollo de hiponatremia dilucional y el tratamiento con vaptanes, que son acuaréticos que bloquean selectivamente los receptores V2 de vasopresina en las células principales del túbulo colector, constituyendo una de las intervenciones farmacológicas más innovadoras en el manejo de la hiponatremia en cirrosis en los últimos años.
Subject(s)
Humans , Ascites/therapy , Liver Cirrhosis/complications , Hyponatremia/therapy , Ascites/classification , Ascites/diagnosis , Ascites/etiology , Liver Cirrhosis/therapy , Diuretics/therapeutic use , Hyponatremia/etiology , Hyponatremia/drug therapy , Paracentesis , Receptors, Vasopressin/antagonists & inhibitors , Severity of Illness IndexABSTRACT
La hipertensión porta (HTP) es el resultado del incremento de la presión dentro del sistema venoso porta. Se presenta con poca frecuencia en el paciente pediátrico pero es una de las mayores causas de morbilidad y mortalidad en el niño con enfermedad hepática. La mayoría de los pacientes con http presentan un estado hiperdinámico, lo cual aumenta el flujo venoso porta y mantiene la hipertensión. Puede ser secundaria a obstrucción a nivel prehepático, intrahepático o extrahehepático.
Portal hypertension (PH) is the result of increased pressure within the portal venous system. It occurs infrequently in the pediatric patient but it is a major cause of morbidity and mortality in children with liver disease. Most patients with PH have a hyperdynamic state, which increases venous flow and portal hypertension remains. May be secondary to obstruction at prehepatic, intrahepatic or extrahehepatic.
Subject(s)
Humans , Male , Female , Child, Preschool , Child , Ascites/classification , Splenomegaly/classification , Splenomegaly/complications , Hematemesis/mortality , Hematemesis/blood , Hypertension, Portal/epidemiology , Hypertension, Portal/mortality , Hypertension, Portal/pathology , Hepatolenticular Degeneration/classification , Hepatolenticular Degeneration/diagnosis , Cystic Fibrosis/classification , Child Nutrition Disorders/etiology , Child Nutrition Disorders/genetics , Child Nutrition Disorders/mortality , Child Nutrition Disorders/bloodABSTRACT
Albumin in ascitic fluid has been evaluated as a discriminative diagnosis test, based on an observation and retrospective study, comparing it to that of total ascitis protein and albumin gradient, which are the most clinically used tests nowadays. The study involved a total of 45 patients, predominantly women, averaging 54 years of age, who were diagnosed through laparoscopy in a public hospital. The evaluation included: 19 patients suffering transudate type ascitis (chronic liver disease, n = 18), 23 patients with exudates type ascitis (peritoneal carcinomatosis, n = 12, tuberculous peritonitis, n = 11), and patients with mixedascitis. Sensibility, specificity and predictive values were obtained from the analysis of the tests, and they were represented through the distribution of averages and ROC curves, showing every time that these tests can be used in clinical practice because they have comparable sensibility and specificity values. As a new discriminative test of transudates and exudates the albumin test in ascitis proved to have a sensibility comparable to that of the protein in ascitic fluid but discreetly lower to that of albumin gradient. However, the ascitis albumin showed a better relation between the sensibility and specificity in the area under the ROC curves. Based on this study, the usefulness of the concentration of albumin in ascitic fluid is highlighted as a new test to discriminate exudates from transudates, which has been reported by very few authors in writing. In addition, this study shows that the albumin gradient can also be applied in the discrimination of exudates and transudates with efficacy comparable to its use in the discrimination of ascitis with or without portal hypertension.
Subject(s)
Albumins , Ascites/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , Ascites/classification , Diagnosis, Differential , Female , Humans , Male , Middle Aged , Predictive Value of Tests , ROC Curve , Serum Albumin/analysisABSTRACT
Prospective evaluation was performed in 60 in-patients, carriers of ascites of different etiologies, analyzing the validity of the parameters depending on protein and albumin dosage, both in the ascitic serum and fluid, for the discrimination of possible etiological causes of ascites, including in these parameters Protein Concentration in the Ascitic Fluid, the Serum-Ascites Albumin Gradient, the Protein Ascites/Serum Ratio, and the Albumin Concentration in the ascitic fluid. Average age was 46.9 +/- 19.6, all female; 21 cases were associated with Chronic Hepatic Disease, 14 to Tuberculosis, 11 to Malignant Neoplasia, 7 to Nephrotic syndrome, 4 to Congestive Heart Failure, 2 to Collagen Disease, and 1 to a severe Malnutrition case. The evaluation parameters correlate with the oncotic and hydrostatic pressures of the Starling Law, on the basis of what they could be compared with, demonstrating that their sensitivity levels and their specificity may be used as positive or negative predictive values in the discriminative evaluations of ascites in relation to its probable etiological causes. Even though the Serum-Ascites Albumin Gradient may be useful in the separation of ascites cases with portal hypertension, it is also useful for classifying exudates and transudates. However, the other parameters must not be excluded for the evaluation of those cases, aiming at establishing whether the peritoneum has been affected and hence the terms transudates and exudates should still be used on the basis of the high sensitivity value and specificity of theses tests, which do not differentiate them statistically from the Serum-Ascites Albumin Gradient. Using the cut-off points for each parameter, the most adequate for our population would be 1.5 gr/dl for Albumin and 2.5 gr/dl for protein, with the additional lower cost benefit.
Subject(s)
Ascites/classification , Ascites/diagnosis , Ascitic Fluid/chemistry , Exudates and Transudates/chemistry , Serum Albumin/analysis , Adolescent , Adult , Aged , Aged, 80 and over , Albumins/analysis , Blood Proteins/analysis , Diagnosis, Differential , Female , Humans , Middle Aged , Predictive Value of Tests , Prospective Studies , Sensitivity and SpecificityABSTRACT
Un problema común en la gastroenterología y en otras áreas de la medicina interna es la ascitis. Esta entidad puede ser la manifestación de diversas patologías. Por esta razón, es necesario conocer el abordaje inicial de estos pacientes, así como sus complicaciones y tratamiento
Subject(s)
Humans , Ascites/classification , Ascites/complications , Ascites/diagnosis , Ascites/therapy , Ascitic Fluid/cytology , Ascitic Fluid/complications , Ascitic Fluid/etiology , Ascitic Fluid/physiopathology , Ascitic Fluid/chemistry , Ascitic Fluid/therapy , Peritonitis/etiologyABSTRACT
Todo paciente con ascitis diagnosticada recientemente requiere una paracentesis diagnóstica la cual debe ser repetida si existe deterioro clínico.
Subject(s)
Humans , Ascites/classification , Ascites/diagnosis , Ascites/etiology , Ascites/therapy , DrainageABSTRACT
A prospective study in thirty one patients with ascites, who were hospitalized at Cayetano Heredia National Hospital (H.N.C.H.), to investigate the association between the high serum-to-ascites albumin concentration gradient (high GRAD-Alb) with the degree and development of oesophageal varices, studied by endoscopy, is here reported. It was also studied its relationship with the degree of impairment of liver function, determined by the Child-Pugh's score. In addition our series found that the degree of high GRAD-Alb could discriminate patients with oesophageal varices finding like a signal of its presence a value of high GRAD-Alb greater than 1.435 +/- 0.015 g/dl. It is here demonstrated that the degree of high GRAD-Alb does not have any relationship with the degree of impairment of liver function (Child-Pugh's score), prothrombine time, serum bilirrubin, degree of encephalopathy neither grade of ascites; however, we found a light association and correlation with serum albumin.
Subject(s)
Albumins/analysis , Ascitic Fluid/chemistry , Hypertension, Portal/diagnosis , Serum Albumin/analysis , Adult , Ascites/classification , Ascites/diagnosis , Bilirubin/blood , Cross-Sectional Studies , Esophageal and Gastric Varices/diagnosis , Esophagoscopy , Fiber Optic Technology , Hepatic Encephalopathy/diagnosis , Humans , Hypertension, Portal/classification , Prospective StudiesABSTRACT
Cirrhosis of the liver is the main cause of ascitis. Recent studies have shown in compensated cirrhotics a 40 percent chance to develop ascitis after five years of follow up. The presence of ascitis is usually associated with advanced liver disease, and higher mortality than patients with compensated cirrhosis. Many theories have been proposed to explain ascitis formation being the most important the presence of portal hypertension and sodium retention. Extravascular fluid accumulation depends directly of a balance between hydrostatic and colloid-osmotic pressure (Starling law). Hepatic sinusoids differ from splanchnic ones in regard to the presence of fenestrae, that allows albumin and other substances to flow freely from the sinusoid to the extravascular space. For these reasons the sinusoids lacks colloid-osmotic pressure, and the hydrostatic pressure regulates the flow of fluids passing through them. In cirrhosis, diffuse fibrosis and nodule formation cause functional obstruction to the hepatic blood flow, and a secondary increase in the sinusoidal pressure, that leads to exit of fluids from the sinusoids to the hepatic lymphatics and the thoracic duct. When the amount of fluid that leaves the sinusoids exceeds the capacity of the thoracic duct, fluids accumulate in the abdominal cvity (ascitis). A new theory about ascitis formation states that the first event is a diffuse peripheral arterial vasodilation that cause ineffective plasma volume that triggers the production of humoral factors directed to retain sodium in the kidney...