Treatment of refractory ascites

Article Abstract:

Ascites is the accumulation of fluid within the peritoneal cavity (the membrane lined cavity of the abdomen). In alcoholic patients ascites is frequently caused as a consequence of blockages of the blood flow from abdominal structures through a degenerating or cirrhotic liver. At least 600,000 Americans are estimated to have cirrhosis, but some experts think that this figure is a gross underestimate. Because most patients with cirrhosis have ascites at sometime during the course of their disease, the recent study and comparison of surgical and medical treatment by Stanley et al. regarding the course of ascites in the New England Journal of Medicine is especially important. The study concludes that a surgical technique, peritoneovenous shunting, more rapidly improves the condition and increases the average length of survival. However, the results of similar trials have not produced completely supporting data. For instance, one study found that the rate of complications for surgically treated patients was greater than for the medically treated patients. In addition, the surgical procedure evaluated in this case is only one of several possible techniques. Recently the effectiveness of the shunting technique was compared with washing the peritoneal cavity, or paracentesis, with a large volume (four to six liters) of fluid per day in conjunction with intravenous albumin. The results of that study showed that both techniques are similarly efficacious, although the surgically treated group had fewer relapses than the group treated by paracentesis. Several new drug approaches to the reduction of the volume of ascites have also been proposed. At this point peritoneal shunting appears to be a proper technique for a select group of patients whose frequency or severity of ascites renders more conservative forms of therapy less desirable. However, large volume paracentesis may be the preferred means of treating patients with ascites that is resistant to other forms of treatment.

editorial

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Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites

Article Abstract:

The accumulation of fluid in the abdominal cavity can be a debilitating consequence of liver cirrhosis. Although not common among cirrhosis patients, this condition, called ascites, may involve the accumulation of four or five gallons of ascites fluid. In many hospitals, this condition is treated with a peritoneovenous shunt, which provides a pathway for this excess fluid to return to the blood, and, ultimately, be removed by the kidneys. Recently, however, several studies have shown that paracentesis is a safe, rapid, and effective method for relieving ascites. Paracentesis is the direct removal of the fluid; it is generally accompanied by the infusion of additional albumin, a blood protein, into the patient's blood. A study was conducted to compare peritoneovenous shunting and paracentesis and determine which is most suitable for the treatment of this condition. A total of 89 patients with ascites were randomly assigned to receive one or the other treatment. Nine of 41 patients receiving paracentesis developed complications as did 15 of the 48 patients undergoing the shunt procedure. Three patients in the paracentesis group and six in the shunt group died during the initial hospitalization. The differences in complications and in deaths were not statistically significant. The ascites fluid was successfully removed in all 41 paracentesis patients and in 44 of the 48 shunt patients. There were no differences between the two groups in the value of the initial treatment. However, it was found that the patients who underwent paracentesis were more likely to be rehospitalized and require rehospitalization sooner than those who received a shunt. Overall, however, the need for hospitalization and patient survival were not significantly different between the two groups. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Evaluation, Complications and side effects, Paracentesis, Peritoneovenous shunts, Peritoneovenous shunt

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Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites

Article Abstract:

Ascites is the accumulation of fluid within the peritoneal cavity, the membrane-lined cavity surrounding the abdominal organs. In alcoholic patients ascites is frequently a consequence of prevention of blood flow from the abdominal structures through a degenerating or cirrhotic liver. This study examines the relative values of a surgical procedure known as peritonovenous shunting and medical treatment of alcoholic cirrhosis and ascites in a population of 299 men drawn from 20 Veterans Administration hospitals over five and a half years. Patients were randomly assigned to either the medical or surgical group and classified according to one of three risk groups depending on the severity of their difficulties. Those with the greatest risk only survived an average of 37 days and there was no statistically valid difference between the two modes of treatment. For the other two groups, surgical treatment was found to provide a more rapid reduction in the original ascites, reduced hospital stays, and greater relief against the recurrence of ascites. However, the mean length of survival and the overall complication rate was not significantly different between the two modes of treatment.

Surgery

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