In this two-part series for healthcare professionals, we explore all you need to know about refractory ascites.
What Is Refractory Ascites?
Refractory ascites is a severe complication of liver cirrhosis. It refers to the condition when fluid continues to accumulate in the abdominal cavity despite the a therapeutic paracentesis. This is due to the significant portal hypertension from cirrhosis.
In such cases, the ascitic fluid cannot be mobilized or it recurs shortly after treatment. This can occur despite the patient’s efforts to limit sodium intake and the administration of a high-dose diuretic treatment.
What Are Ascites and Their Associated Risks?
Ascites is free peritoneal fluid, typically over 25 milliliters, that collect inside the abdomen between the organs and abdominal lining.
Life Expectancy With Ascites
Up to 75% of patients with ascites over a 10-year follow-up period have cirrhosis and suffer a 50% mortality rate over two years, making it the single most common risk factor associated with ascites. The life expectancy with ascites in cirrhosis is a critical consideration in understanding the gravity of this condition.
But they may also have other causes, including:
- Heart failure, which accounts for around 3% of cases
- Tuberculosis, accounting for around 2%
- Pancreatic diseases like chronic pancreatitis which accounts for 1%
- Malignant ascites
Other causes account for around 2% of cases:
- Obesity
- High cholesterol levels
- Intravenous drug use
- Ovarian lesions
- Kidney disease
- Severe malnutrition
- Type 2 diabetes
- Pancreatic, endometrial, or liver cancer
Hemorrhagic ascites are slightly different from typical ascites. They occur when blood is present in the fluid. They happen if the patient has blood in their lymph fluid or liver cancer.
Since cirrhosis is the biggest cause of ascites, it’s important to know the causes of liver damage:
- Chronic hepatitis C
- Chronic hepatitis B
- Non-alcoholic fatty liver disease
- History of high alcohol consumption
- Chronic heart failure with liver congestion
- Long-term use of anabolic steroids, methotrexate, and other drugs
- Inherited diseases such as hemochromatosis and Wilson’s disease
- Autoimmune hepatitis
- Primary biliary cholangitis or primary sclerosing cholangitis
- Diseases that block bile ducts
Cirrhotic ascites develops due to high blood pressure in the portal vein (portal hypertension) which carries blood from the digestive organs to the liver. The rising pressure increases hydrostatic pressure in the portal vein that leads to fluid build up in the abdomen.
The liver struggles to manage this fluid, which is then forced into the abdominal cavity. This ultimately results in the formation of ascites.
In cases involving peritoneal cancer, tumor cells in the abdominal lining or the peritoneum produce proteinaceous fluid. This can then form malignant ascites.
In instances of kidney or heart failure, the reduction of the blood volume in the arteries may trigger changes in bodily systems. These can cause the kidney’s blood vessels to constrict, potentially leading to sodium and water retention that then form ascites.
How To Diagnose Ascites
Main refractory ascites symptoms:
- Painless abdominal swelling that gets worse or does not go away
- Weight gain
- Discomfort in the abdomen
- Feeling full after eating a little
- Tenderness in the abdomen
- Fever
- Confusion
- Bloating
- Heartburn
- Nausea and vomiting
These symptoms are typically associated with complications such as:
- Pleural effusion
- Hepatorenal syndrome
- Bacterial infections
- Hernias
Diagnosing ascites requires multiple steps, including a checkup and tests such as:
- Blood tests
- MRI scan
- Laparoscopy
- CT scan
- Ultrasound
These tests can help practitioners look for accumulated fluid. In addition to conducting thorough abdominal examinations, they are essential for accurate diagnoses.
How Can Ascites Be Treated?
Treatment depends on the cause of the condition. If it’s caused by a viral or bacterial infection, therapy can be used to relieve ascites symptoms while treating the underlying cause.
Other common treatment methods for ascites include:
Paracentesis
This involves injecting a long, thin needle into the abdominal cavity to remove the excess fluid in the abdomen. Paracentesis is typically used if symptoms do not improve with the administration of diuretics.
Diuretics
Known for their effectiveness, diuretics are the most common treatment option for ascites. These drugs increase the amount of salt and water leaving the body, reducing pressure in the veins surrounding the liver. When using diuretics, it is important that the patient reduce their salt and alcohol intake while having their blood chemistry monitored.
Surgery
In some situations, a permanent tube or shunt may be placed in the body to reroute the blood flow around the liver. This reduces portal hypertension and the need for regular drainage and is a suitable alternative if diuretics prove ineffective.
A liver transplant can be an option in case of severe liver disease or if the ascites don’t respond to treatment. Surgery is also an option if the ascites are a result of heart failure.
Final Thoughts
When the abdominal region fills with fluid, the condition is referred to as ascites. While ascites can be treated with diuretics, surgery, or paracentesis, some patients may experience recurrent ascites or persistent ascites that do not recede with treatment. These are known as refractory ascites.
We hope that the first part of our article on ascites has provided you with a basic understanding of the subject. Explore more on this topic in the second part of this study.
If you’d like to undergo formal training on the management of ascites, Hospital Procedures Consultants’ Paracentesis Course covers how to drain ascitic fluid and how paracentesis can be used to treat ascites and identify its cause.
References
Will, V, Rodrigues, S, Berzigotti, A. Current treatment options of refractory ascites in liver cirrhosis – A systematic review and meta-analysis. Dig Liver Dis. 2022 Aug;54(8):1007-1014
Wonf, F. Management of refractory ascites. Clin Mol Hepatol. 2023 Jan;29(1):16-32.
Leache, L. Gutierrez Valencia, M. Saiz, C. Uriz, J. Bolado, F. Garcia, J. Cantarelli, L. Eviti, J. Meta-analysis: Efficacy and safety of albumin in the prevention and treatment of complications in patients with cirrhosis. Aliment Pharmacol Ther. 2023 Mar;57(6):620-634
Siqueira, F. Kelly, T. Saab, S. Refractory Ascites. Gastroenterol Hepatol. 2009 Sep; 5(9): 647–656.