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Query: UMLS:C0023890 (cirrhosis)
 42,195 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The pathogenesis and diagnosis of cirrhotic ascites are reviewed, and the treatment options are described, focusing on pharmacologic management. The major theories on the pathogenesis of cirrhotic ascites are the underfill and overflow theories. The underfill theory states that ascites formation results in decreased plasma volume leading to renal sodium and water retention. The overflow theory states that the initial event in ascites formation is renal sodium retention. Evidence suggests that the formation of ascites is a continuum involving both overflow (early) and underfill (late) mechanisms. Although the most frequent cause of ascites is hepatic cirrhosis, analysis of the ascitic fluid is important to exclude other causes (e.g., neoplasm, peritonitis, pancreatitis). Patients who do not respond to treatment with sodium restriction and bed rest require diuretic therapy. Spironolactone is the agent of choice for treatment of the nonazotemic patient with cirrhotic ascites. Combination therapy with spironolactone and furosemide or spironolactone and metolazone may be used in those patients who do not respond to spironolactone. Patients with impaired renal function should not be treated with spironolactone because of the risk of hyperkalemia. Paracentesis with albumin replacement has been used successfully for treatment of patients with tense cirrhotic ascites. Initial management of cirrhotic ascites is conservative, with sodium restriction and bed rest. Spironolactone is a good first-choice drug for treatment of ascites. Daily weight, serum electrolytes, and renal function should be monitored to assess the effectiveness and potential adverse effects of diuretic therapy.
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PMID:Management of cirrhotic ascites. 267 16

Cirrhosis is associated with several circulatory abnormalities. A hyperkinetic circulation characterized by increased cardiac output and decreased arterial pressure and peripheral resistance is typical. Despite this hyperkinetic circulation, some patients with alcoholic cirrhosis have subclinical cardiomyopathy with evidence of abnormal ventricular function unmasked by physiologic or pharmacologic stress. Florid congestive alcoholic cardiomyopathy develops in a small percentage, but the concurrent presence of cirrhosis seems to retard the occurrence of overt heart failure. Even nonalcoholic cirrhosis may be associated with latent cardiomyopathy, although overt heart failure is not observed. Tense ascites is associated with some cardiac compromise, and removing or mobilizing ascitic fluid by paracentesis or peritoneovenous shunting results in short-term increases in cardiac output. Cirrhosis also appears to be associated with a decreased risk of major coronary atherosclerosis and an increased risk of bacterial endocarditis. Small hemodynamically insignificant pericardial effusions may be seen in ascitic patients. The release of atrial natriuretic peptide appears to be unimpaired in cirrhosis, although the kidney may be hyporesponsive to its natriuretic effects.
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PMID:Cardiac abnormalities in liver cirrhosis. 269 Apr 63

To investigate whether paracentesis could be an alternative therapy for ascites, 117 cirrhotics with tense ascites were randomly allocated into two groups. Fifty-eight patients (group 1) were treated with paracentesis (4-6 L/day until disappearance of ascites) and intravenous albumin infusion (40 g after each tap). Fifty-nine patients (group 2) were treated with spironolactone (200-400 mg/day) plus furosemide (40-240 mg/day). Patients from group 2 not responding to diuretics were treated with a LeVeen shunt. After disappearance of ascites, patients from both groups were discharged from hospital and were instructed to take diuretics. Patients developing tense ascites during follow-up were readmitted to hospital and treated according to their initial schedule. Paracentesis was effective in eliminating the ascites in 56 patients from group 1 (96.5%) and did not induce significant changes in renal and hepatic function, plasma volume, cardiac index, peripheral resistance, plasma renin activity, plasma norepinephrine and antidiuretic hormone concentration, and urinary excretion of prostaglandin E2 and 6-keto-prostaglandin F1 alpha. Diuretics were effective in eliminating the ascites in 43 patients from group 2 (72.8%) (p less than 0.05). Ten patients in group 1 and 36 in group 2 developed complications during their first hospital stay (p less than 0.001). This difference was due to the significantly higher incidence of hepatic encephalopathy, renal impairment, and electrolyte disturbances occurring in patients treated with diuretics. The duration of hospital stay was 11.7 +/- 1.5 days for patients from group 1 and 31 +/- 2.8 days for patients from group 2 (p less than 0.001). The two groups did not differ significantly with respect to the probability of requiring readmission to hospital during follow-up, reasons for readmission, survival probability after entry into the study, and causes of death. These results indicate that paracentesis associated with intravenous albumin infusion is a fast, effective, and safe therapy for ascites in patients with cirrhosis.
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PMID:Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. 329 7

Nadolol, a nonselective beta-blocker, has been shown to decrease portal pressure in patients with cirrhosis at the same degree as propranolol. No data are available, however, about its effect on rebleeding rate and mortality in patients undergoing prevention of rebleeding from esophageal varices. A prospective randomized clinical trial was performed in patients with cirrhosis who survived a documented episode of variceal hemorrhage. 12 patients received nadolol, 12 placebo. Patients with child's C grade, tense ascites, renal failure, contraindications to beta-blocker, or age greater than 70 were not included. After a follow-up of up to 145 weeks, 9 patients in the nadolol group and 4 in the placebo group survived free from rebleeding (log-rank test: chi 2 = 4.35, p less than 0.05). Survival was not statistically different in the two groups (1 death in the nadolol group, 3 in the placebo group). In conclusion, nadolol appears to represent an effective therapy in the prevention of variceal rebleeding in cirrhotic patients.
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PMID:Nadolol for prevention of variceal rebleeding in cirrhosis: a controlled clinical trial. 330 78

It has recently been shown that repeated large-volume paracentesis associated with intravenous albumin infusion is a rapid, effective, and safe therapy of ascites in cirrhosis. To investigate whether intravenous albumin infusion is necessary in the treatment of cirrhotics with large-volume paracentesis, 105 patients with tense ascites were randomly allocated into two groups. Fifty-two patients (group 1) were treated with paracentesis (4-6 L/day until disappearance of ascites) plus intravenous albumin infusion (40 g after each tap), and 53 (group 2) with paracentesis without albumin infusion. After disappearance of ascites, patients were discharged from the hospital with diuretics. Patients developing tense ascites during follow-up were treated according to their initial schedule. Paracentesis was effective in eliminating the ascites in 50 patients from group 1 and in 48 from group 2, with the duration of the hospital stay being approximately 11 days in both groups. Paracentesis plus intravenous albumin did not induce significant changes in standard renal function tests, plasma renin activity, and plasma aldosterone. In contrast, paracentesis without albumin was associated with a significant increase in blood urea nitrogen, a marked elevation in plasma renin activity and plasma aldosterone concentration, and a significant reduction in serum sodium concentration. One patient from group 1 and 11 from group 2 developed renal impairment or severe hyponatremia after treatment, or both (chi 2 = 9.19; p less than 0.01). The development of these complications could not be predicted by clinical and laboratory data before treatment. Although the probability of survival after entry into the study was similar in patients from both groups, a multivariate analysis identified the development of hyponatremia or renal impairment, or both, following the first paracentesis treatment and the occurrence of other complications during the first hospitalization (encephalopathy, gastrointestinal bleeding, and severe infection) as being the only independent predictors of mortality. These results indicate that intravenous albumin infusion is important in avoiding renal and electrolyte complications and activation of endogenous vasoactive systems in cirrhotics with ascites who are treated with repeated large-volume paracentesis. The development of such complications may impair survival in these patients.
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PMID:Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. 336 Feb 70

Thirteen patients with cirrhosis and tense ascites (six with and seven without peripheral edema) underwent 4- to 15-liter paracentesis without intravenous "colloid" replacement. Cardiac output increased from 6.6 +/- 0.7 liters per min at baseline to 8.2 +/- 0.7 liters per min (p less than 0.003) 1 hr after large-volume paracentesis completion and fell to 7.5 +/- 0.69 liters per min (p less than 0.05 vs. baseline, p less than 0.02 vs. 1 hr) 24 hr after large-volume paracentesis completion. There was no change in mean arterial pressure or mean pulmonary artery pressure. Central venous pressure fell from 9.1 +/- 0.8 mm Hg at baseline to 8.6 +/- 1.4 mm Hg 1 hr post-large-volume paracentesis to 6.8 +/- 1.0 mm Hg (p less than 0.005 vs. baseline, p less than 0.02 vs. 1 hr value) at 24 hr, and pulmonary capillary wedge pressure fell from 13.1 +/- 0.9 to 11.1 +/- 1.3 mm Hg 1 hr after large-volume paracentesis and to 9.89 +/- 1.2 (p less than 0.01 vs. baseline, p less than 0.03 vs. 1 hr after large-volume paracentesis) at 24 hr. Heart rate fell from 90 +/- 3.0 to 85 +/- 2.9 beats per min (p less than 0.01) 1 hr after large-volume paracentesis completion, but increased to 89 +/- 2.5 beats per min (p less than 0.02 vs. 1 hr after large-volume paracentesis) at 24 hr.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Effects of therapeutic paracentesis on systemic and hepatic hemodynamics and on renal and hormonal function. 357 Jan 54

A model of lymphatic conductivity (i.e. flow rate per unit pressure difference = conductance) based on protein-kinetic and haemodynamic measurements is described. The model is applied to data from patients with cirrhosis and from pigs with different haemodynamic abnormalities in the hepatosplanchnic system. In cirrhotic patients without ascites the estimated thoracic duct conductance (gthd) was three times higher than normal whereas this value was close to normal in patients with tense ascites. The estimated conductance of the right lymphatic duct was ten times below that of the thoracic duct in patients with ascites. In pigs gthd was similar to that in normal humans and no change was seen during acute congestion of the liver. In ascitic pigs gthd was low. The estimated conductance of the liver blood-lymph barrier was similar in normal humans and pigs, but decreased in cirrhosis and was thus compatible with increased sinusoidal wall tightening and fibrosis in the interstitial space of the liver. The model presented supports the so-called 'lymph-imbalance' theory of ascites formation according to which a relatively insufficient lymph drainage is important in the pathogenesis of hepatic ascites.
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PMID:Estimation of lymphatic conductance. A model based on protein-kinetic studies and haemodynamic measurements in patients with cirrhosis of the liver and in pigs. 400 22

We determined the levels of total intraabdominal pressure and the tension resulting from the distention of the abdominal wall in 12 patients with ascites resulting from alcoholic cirrhosis of the liver. The measurements were performed first when ascites was tense, and were repeated later when ascites became non-tense with treatment. Using intraperitoneal injections of 131I-labeled human serum albumin, we measured the ascites volume and the resorption of albumin from the ascitic compartment at the same time as the pressure studies. Reduction in intra-abdominal pressure from 29.5 +/- 4.1 to 21.7 +/- 6.0 cm H2O (p less than 0.001) and in tension from 8.3 +/- 2.7 to 2.9 +/- 1.6 cm H2O (p less than 0.001) did not result in significant changes in resorption of albumin from the peritoneal cavity. Lowering of intra-abdominal pressure was not associated with any change in the volume of the resorbed ascitic fluid or the amount of albumin resorbed. We conclude that the ascites resorption rate in cirrhosis is not linearly related to intra-abdominal pressure and that in tense ascites, the decreased permeability of the parietal peritoneum counteracts the effects of the increased intra-abdominal pressure on albumin resorption. Cirrhotic ascites is associated with a changing permeability of the peritoneal membrane.
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PMID:Intraabdominal pressure and resorption of ascites in decompensated liver cirrhosis. 674 42

A retrospective was designed to analyse the mode of presentation, clinical signs and haematological and biochemical abnormalities in 225 consecutive Black (Zulu) patients who were admitted to a general medical ward between the years 1970 and 1981 and in whom cirrhosis was later diagnosed. The most common presenting complaint was swelling of the body (60% of the patients), followed by abdominal pain (32%) and episodes of bleeding, mainly from the gastrointestinal tract (19%). On examination, hepatomegaly was encountered in 66% of the patients, with moderate to massive enlargement in 40%. Ascites was detected in 56%, with tense abdominal distension in 34%. Jaundice was present in 38% and emaciation, mental disturbance and splenomegaly in over 25%. Spider naevi (found in 2 patients) and Dupuytren's contracture (found in 1) were very rare. Thrombocytopenia and a high ESR were common. Over 90% of patients had low albumin and high globulin concentrations (albumin less than 20 g/dl and globulin greater than 60 g/dl in 25%). Bilirubin and alkaline phosphatase levels and the prothrombin index were found to be within normal limits in 32%, 24% and 52% of cases respectively. Histologically the lesion was most commonly micronodular (73%) with variable deposits of fat and iron. Peritoneoscopy was the most useful special investigation in the diagnosis of cirrhosis, leading to a correct diagnosis in 77% of cases. In conclusion, the clinical signs, biochemical abnormalities and histological features suggest that the factors causing cirrhosis in the community studied are mixed; it may result from the combined effects of alcohol abuse, malnutrition and chronic viral (e.g. hepatitis B) infections.
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PMID:Clinical presentation and biochemical abnormalities in black (Zulu) patients with cirrhosis in Durban. 707 88

For 5 years (1976-1981) peritoneovenous shunting has been used in 32 patients with intractable ascites--that is, in patients in whom medical therapy has failed. All operations but one were performed using local anesthesia. The LeVeen shunt was used in 29 patients and the Denver shunt in three patients. Good palliation was achieved in 14 of 23 patients with ascites due to liver cirrhosis. Seven out of eight patients with tense ascites secondary to malignancy were relieved. Complications were seen in six patients. In one patient severe disseminated intravascular coagulopathy made removal of the shunt necessary. Leakage, local infection, and skin necrosis, when present, could successfully be treated without removing the shunt. The surgical procedure is simple and offers relief to most patients with tense ascites resistant to medical therapy.
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PMID:Peritoneovenous shunting for intractable ascites. 716 35


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