Page 7 - 02- Ascites (Cổ chướng)

Automated low-flow ascites pump drains ascitic fluid from peritoneal cavity to urinary bladder
for elimination. Mainly used in patients with contraindication to TIPS placement or liver
transplant.
Cell free and concentrated ascites reinfusion:
– Used for management of malignant ascites. Protein collected from filtration and
concentration of ascitic fluid is reinfused intravenously
Peritoneovenous shunt (LeVeen or Denver shunt): drains ascites directly into the inferior vena
cava
– Trials show poor long-term shunt patency, no survival advantage.
– Complications include bacteremia, bowel obstruction, and variceal bleed.
– Reserved for patients with refractory ascites who are not candidates for TIPS or liver
transplant and who can’t tolerate repeat paracentesis (1)[C]
Indwelling catheters with external drainage
– Most useful in malignant ascites as a palliative measure (can be drained at home)
– Overall low rate of infection
Avoid percutaneous endoscopic gastrostomy (PEG) tube placement in patients with ascites due
to high postprocedure mortality rate (1)[B].

ONGOING CARE

PROGNOSIS
Prognosis varies depending on underlying cause.
Ascites in itself is rarely life-threatening but can signify life-threatening underlying disease
(e.g., cancer, end-stage liver disease).

COMPLICATIONS
SBP
3
– Ascitic fluid PMN leukocyte count ≥250 cells/mm or positive culture
Broad-spectrum antibiotics are as follows: Cefotaxime 2 g q8h or similar 3rd-generation
cephalosporin is the treatment of choice for suspected SBP; covers 95% of flora
(including Escherichia coli, Klebsiella, pneumococci) (1)[A]; broader coverage often
required for hospital-acquired infections
Levofloxacin is an alternative for patients who are not on long-term fluoroquinolones or
who are allergic to penicillins or β-lactams.
Consider SBP prophylaxis in: GI bleeding, previous SBP episode, or ascitic fluid protein
less than 10 g hospitalized for reasons other than SBP.
Suspect primary bacterial peritonitis (PBP) due to bowel perforations when ascitic fluid.
3
3
>250 cells/mm (often >5,000 cells/mm ) and any two of the following:
Ascitic fluid total protein >1 g/dL (often >3 g/dL)
Ascitic fluid glucose <50 mg/dL (or 2.8 mmol/L)
Ascitic fluid LDH that is 3-fold greater than serum LDH
Hepatorenal syndrome: Type 1: rapid acute worsening of renal function evolving in the setting
of a known precipitating factor. Type 2 is more slowly progressive in the setting of refractory
ascites.
Cellulitis is common in obese patients with brawny edema. Treat with diuretics and antibiotics