Treatment of refractory ascites

Comparison of clinical outcomes of transjugular intrahepatic portosystemic shunt for refractory ascites and recurrent nonrefractory ascites

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) has an important role in the therapy of complications of portal-hypertension-related ascites. Various guidelines now indicate that TIPS is indicated for refractory ascites (RA), but TIPS for recurrent nonrefractory ascites (RNRA) achieved better clinical results.

AIM

To compare the clinical outcomes of TIPS for RA and RNRA in patients with complications related to portal hypertension.

METHODS

There were 863 patients divided into two main categories who underwent TIPS between September 2016 and September 2021. In category 1, patients had ascites without cirrhotic gastrointestinal bleeding. The patients were divided into group A (RNRA, n = 183) and group B (RA, n = 217). In category 2, patients had ascites and cirrhotic gastrointestinal bleeding. The patients were divided into group C (RNRA, n = 328) and group D (RA, n = 135). The clinical outcomes were probability of total hepatic impairment, incidence of hepatic encephalopathy (HE) and mortality.

RESULTS

The symptoms of ascites disappeared or were relieved within 1 week in group A compared with group B (P = 0.032), and in group C compared with group D (P = 0.027). By the end of follow-up, there were significant differences in the rate of RA in group A compared with group B (P = 0.016), and in group C compared with group D (P = 0.012). The probability of total hepatic impairment was significantly different in group A compared with group B (P = 0.024), and in group C compared with group D (P = 0.019). The total incidence of HE was significantly different in group A compared with group B (P = 0.008), and in group C compared with group D (P = 0.004). The 6-month, and 1-, 2- and 3-year survival rates were significantly different between groups A and B (all P < 0.05), and between groups C and D (all P < 0.05).

CONCLUSION

TIPS has a good therapeutic effect on ascites related to cirrhotic portal hypertension, and early TIPS for RNRA can prolong survival, and prevent progression to RA.

Ascites Index - an attempt to objectify the assessment of ascites

Introduction: Ascites is observed in cancer patients as well as in other non-neoplastic processes. In some patients, it may cause severe symptoms that can become directly life-threatening. The assessment of the degree of ascites seems useful in the determination of treatment effects as well as in the monitoring of fluid accumulation and early planning of decompression procedures. Aim: Determination of the clinical usefulness of a quantitative method of determining the degree of ascites, so-called Ascites Index. Material and methods: The Ascites Index is an ultrasonographic way of assessing the grade of ascites. The examination result is an index which is analogous to the amniotic fluid index determined in pregnant patients. The Ascites Index was determined in patients with ascites in the course of stage III–IV ovarian carcinoma (7 patients) and ovarian hyperstimulation syndrome (12 patients). Results: The patients with ovarian hyperstimulation syndrome required decompressive paracentesis at the median Ascites Index above 290 mm (range: 216–386 mm). In the patients with ovarian carcinoma, the median value of the Ascites Index at which paracentesis was required was 310 mm (range: 273–389 mm). To avoid complications associated with excessive protein loss, 2000 mL of fluid was evacuated at a single occasion. Following the procedure, the median value of the Ascites Index was 129 mm (range: 121–145 mm) in the patients with ovarian hyperstimulation syndrome and 146 cm (119–220 mm) in cancer patients. Conclusions: The proposed index is simple and rapid to determine. It makes evaluation of the degree of ascites considerably easier. Moreover, it only minimally burdens patients and enables assessment of the effect of decompression or treatment. It seems that this method might be useful also in the assessment of ascites caused by other factors, but this requires further clinical studies.

Management of non-ovarian cancer malignant ascites through indwelling catheter drainage

Backgrounds

Intra-abdominal placement of the Central Venous Catheter (CVC) was conducted to manage the ascites-related symptoms of non-ovarian cancer patients. The aim of this study is to document the efficacy of symptom relief and conduct survival analysis of non-ovarian cancer patients with malignant ascites who received paracentesis and indwelling catheter drainage.

Methods

Seventy eight patients received paracentesis and drainage. All patients who met the inclusion criteria were included in this study. The overall survival (OS) was defined as the interval between initial diagnosis and death. Since-paracentesis survival (SP-Survival) was defined as the interval between initial paracentesis and death.

Results

Hepatic cancer was the most frequent original cancer in this study. Peritoneal catheters remained in situ for a median of 13 days. No immediate complications, such as perforation of a viscus or excessive bleeding, were encountered during placement. All ascites-related symptoms improved after drainage compared with the baseline. There was a statistically significant improvement in the mean score for abdominal swelling (p < 0.001), anorexia (p = 0.023) and constipation (p = 0.045). Cancer type was shown to be an independent prognostic factor for overall survival length (p = 0.001). Serum albumin was an independent prognostic factor for SP-survival (p = 0.02).

Conclusions

Paracentesis and indwelling catheter drainage through CVC set is a useful method for improving painful symptom. Further research is needed to validate the findings.

Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience

Severe portal hyperperfusion (PHP) after liver transplantation has been shown to cause intrahepatic arterial vasoconstriction secondary to increased adenosine washout (hepatic artery buffer response). Clinically, posttransplant PHP can cause severe cases of refractory ascites and hydrothorax. In the past, we reported our preliminary experience with the use of splenic artery embolization (SAE) as a way to reduce PHP. Here we present our 5-year experience with SAE in orthotopic liver transplantation (OLT). Between January 2007 and December 2011, 681 patients underwent OLT at our institution, and 54 of these patients underwent SAE for increased hepatic arterial resistance and PHP (n=42) or refractory ascites/hepatic hydrothorax (n=12). Patients undergoing SAE were compared to a control group matched by year of embolization, calculated Model for End-Stage Liver Disease score, and liver weight. SAE resulted in improvements in hepatic artery resistive indices (0.92±0.14 and 0.76±0.10 before and after SAE, respectively; P<0.001) and improved hepatic arterial blood flow (HAF; 15.6±9.69 and 28.7±14.83, respectively; P<0.001). Calculated splenic volumes and spleen/liver volume ratios were correlated with patients requiring SAE versus matched controls (P=0.002 and P=0.001, respectively). Among the 54 patients undergoing SAE, there was 1 case of postsplenectomy syndrome. No abscesses, significant infections, or bleeding was noted. We thus conclude that SAE is a safe and effective technique able to improve HAF parameters in patients with elevated portal venous flow and its sequelae.

The use of terlipressin in cirrhotic patients with refractory ascites and normal renal function: a multicentric study

Ascites is a common complication of liver cirrhosis, occurring in more than 50-60% of the patients within 10 years of the diagnosis. In 5-10% of patients, ascites cannot be mobilized, or its early recurrence cannot be prevented by medical treatment. This condition is known as "refractory ascites". The use of terlipressin in cirrhotic patients with refractory ascites and normal renal function has not been evaluated. This prospective study was aimed at evaluating whether terlipressin in addition to standard therapy (diuretics plus albumin) might improve the outcome of refractory ascites in cirrhotic patients without HRS.

PATIENTS

26 cirrhotic patients with refractory ascites were prospectively enrolled in this study. All the patients had tense (grade 3) ascites, and 10/26 showed also massive peripheral edema. Patients received maximum diuretic treatment plus albumin and terlipressin.

RESULTS

Complete response was seen in 16/26 patients. The higher response to therapy was seen during the 2nd week of treatment. 6 patients showed a decrease of at least two points in the ascites score. No differences in clinical response to treatment were seen according to the etiology of the disease.

CONCLUSIONS

In conclusion, our study shows a synergistic effect of terlipressin vs treatment with albumin plus diuretics in patients with refractory ascites. One could speculate that albumin might enhance the vasoconstrictive response to terlipressin, thus contributing to counterbalance the negative effects of systemic vasodilation, which characterizes the hyperdynamic circulation of cirrhotic patients.

Comparison of surface electromyography in respiratory muscles of healthy and liver disease patients: preliminary studies

INTRODUCTION

Surface electromyography (SEMG) is described as a technique to detect voluntary muscle activity. In the respiratory muscles, diaphragm and the rectus abdominis-are especially important for respiratory compliance.

OBJECTIVE

We sought to study the activity of muscles using SEMG of the right diaphragm and the right rectus abdominis in healthy subjects versus liver disease patients (LDS).

METHOD

Each group of 30 male patients underwent SEMG with electrodes attached to the dermis surface at the xiphoid and below the right costal margin (channel 1). For the rectus abdominis, we placed the electrodes on the right 5 cm below the umbilicus. The variables studied were: root mean square (RMS), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). We also evaluated age, weight, body mass index, smoking history lifestyle sedentary preexistent chronic lung disease. Nonparametric tests were used for statistical analysis.

RESULTS

There were significant differences (P>0001) between the groups regarding MEP and MIP values showing low pressures in the LDS group. RMS of the rectus abdominis showed a trend (P=.059) toward compliance in the LDS group. Compared with the healthy subjects, there were 18% versus 5% sedentary individuals; only 10% versus 27.3% were smokers or former smokers and chronic lung disease was present in 2% versus 4%.

CONCLUSION

The respiratory muscle evaluation using SEMG detected decreased respiratory muscle strength and a trend to rectus abdominis compliance among LDS.