Page 5 - 02- Ascites (Cổ chướng)

Cytology may reveal malignant cells: adenocarcinoma (ovary, breast, GI tract) or primary
peritoneal carcinoma (most commonly associated with ascites).

TREATMENT

For all patients, first-line treatment consists of:
Daily weight
Restrict dietary sodium to ≤2 g/day if the cause is due to portal hypertension (high SAAG).
Water restriction (1.0 to 1.5 L/day) only necessary if serum sodium <120 to 125 mEq/L
Avoid alcohol and ensure adequate nutrition if liver disease.
Baclofen may be used to reduce alcohol craving/consumption in EtOH cirrhosis.
MEDICATION

ALERT
Care with diuresis; aggressive diuresis can induce prerenal acute kidney injury (AKI),
encephalopathy, and hyponatremia. Monitor creatinine and electrolytes closely. Serum
creatinine >2 mg/dL or serum sodium <120 mmol/L warrants withdrawal of diuretics.
Avoid nonsteroidal anti-inflammatory drugs (can exacerbate oliguria/azotemia).
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)
may be harmful in patients with cirrhosis/ascites due to an increased risk of hypotension and
renal failure. Avoid in refractory ascites.
Consider discontinuing β-blockers in patients with refractory ascites, SBP, worsening
hypotension (SBP <90 mm hg), AKI, hyponatremia <130 mEq/L, or azotemia.

First Line
Sodium restriction and diuretics are the mainstay of treatment for patients with elevated portal
pressures; other causes (e.g., carcinomatosis) are less likely to respond to medical therapy.
– Spironolactone 100 to 400 mg daily PO; typical initial dose is 100 to 200 mg given in am.
Diuretic of choice due to antialdosterone effects; can be used as single agent in minimal
ascites. Monitor for hyperkalemia.
– Furosemide 40 to 160 mg daily PO; typical initial dose is 40 mg given in am.
Antinatriuretic effect helps achieve negative sodium balance.
Preferred in combination with spironolactone rather than as monotherapy
– Most common (and preferred) regimen is spironolactone and furosemide together
(maintaining a 100:40 ratio) for maximum efficacy and to maintain potassium homeostasis.
Titrate dose to desired result (1–Daily weight loss no more than 0.5 kg/day in patients
without peripheral edema and 1 kg/day in patients with peripheral edema. 2–Urinary
sodium output more than the sodium intake.), and monitor renal function regularly.
Follow daily weight.
Adjust ratio to maintain normal potassium.
Diuretic-intractable/refractory ascites (RA) (10% of patients—50% mortality in 6 months)
defined as:
– 1) Persistent or worsening ascites despite maximum doses of spironolactone (400 mg/day)
and furosemide (160 mg/day) for at least 1 week
– 2) Recurrence of grade 2 or 3 ascites within 4 weeks of achieving minimal ascites
– 3) Diuretic induced complications like hepatic encephalopathy, hyponatremia to <125