Make it easier to collect ascites - Treatment strategy for ascites caused by liver cirrhosis

Author: Zhang Haiyan, The Fifth Medical Center, PLA General Hospital

Reviewer: Jin Bo, Chief Physician, Fifth Medical Center, PLA General Hospital

Cirrhosis refers to a pathological process in which the liver tissue undergoes extensive fibrosis, pseudolobule formation, and intrahepatic and extrahepatic vascular proliferation due to long-term damage, leading to disordered liver structure and decreased function. The harm of cirrhosis is far-reaching. It not only affects the liver's detoxification and metabolism functions, but may also cause a series of serious complications, among which ascites (peritoneal effusion) is the most common "uninvited guest". The accumulation of a large amount of ascites not only causes physical discomfort such as abdominal distension and dyspnea to the patient, but may also induce life-threatening complications such as infection and hepatorenal syndrome. Therefore, understanding the treatment principles after the onset of ascites in patients with cirrhosis and the rational use of diuretics are of great significance for controlling the progression of the disease and improving the quality of life of patients. Today, we will deeply analyze the relevant knowledge of ascites, a complication of cirrhosis, especially the rational use of diuretics, to reveal the key to the treatment of ascites in cirrhosis.

Figure 1 Copyright image, no permission to reprint

1. What are the treatment principles for ascites due to cirrhosis?

The treatment goal of ascites in cirrhosis is to eliminate or basically control ascites, improve clinical symptoms, improve quality of life, and prolong survival. Specific treatment principles include the following points.

1. First-line treatment

(1) Etiological treatment

(2) Reasonably limit salt intake (4-6 g per day); use diuretics such as spironolactone and/or furosemide.

(3) Avoid the use of nephrotoxic drugs.

2. Second-line treatment

(1) Rational use of vasoconstrictors and other diuretics, such as terlipressin, midodrine hydrochloride, and tolvaptan.

(2) Abdominal puncture to drain ascites and supplement human serum albumin.

(3) Perform intrahepatic portosystemic shunt via the internal jugular vein.

(4) Discontinue use of nonsteroidal anti-inflammatory drugs, vasodilators, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers.

3. Third-line treatment

(1) Liver transplantation.

(2) Ascites concentration and re-infusion or renal replacement therapy.

(3) Peritoneal drainage pump or peritoneal vena venous Denve shunt.

2. What are the commonly used diuretics? What are the common adverse reactions?

1. Diuretics are divided into potassium-sparing diuretics (spironolactone, triamterene, amiloride) and potassium-excreting diuretics (torsemide, furosemide, bumetanide, hydrochlorothiazide) according to their potassium-sparing and potassium-excreting effects.

2. Common adverse reactions

(1) Common adverse reactions of potassium-sparing diuretics: ① Hyperkalemia and hyponatremia, manifested as weakness in the limbs, nausea, vomiting, blurred vision, and poor appetite; ② Anti-androgen-like effects or effects on other endocrine systems. Long-term use can cause breast development, erectile dysfunction, and sexual dysfunction in men, and can cause breast pain, hoarseness of the voice, increased hair growth, menstrual disorders, and sexual dysfunction in women.

(2) Common adverse reactions of potassium-excreting diuretics: ① Hypokalemia, hyponatremia, and hypocalcemia, manifested as fatigue, dry mouth, thirst, arrhythmia, muscle aches, nausea, and vomiting; ② Long-term use may cause hypochloremic alkalosis, hyperuricemia, glucose metabolism disorders, orthostatic hypotension, ototoxicity (hearing impairment), blurred vision, etc.

3. Do diuretics need to be taken for a long time? What should I pay attention to when taking them?

1. Blood pressure, urine volume, and body weight should be monitored while taking diuretics, and electrolytes, liver function, kidney function, abdominal ultrasound, etc. should be checked regularly. The doctor will adjust the type and dosage of diuretics based on the blood and ultrasound results to avoid excessive diuresis and blind use of drugs to prevent adverse reactions.

2. Precautions when taking diuretics

(1) The first dose should be started with a small dose and gradually increased to the therapeutic dose.

(2) Avoid taking the medicine too late. Taking the medicine during the day will facilitate urination and help you sleep at night.

(3) It is best to take the drug after meals, which helps reduce gastrointestinal reactions and improve drug bioavailability.

(4) Do not stop taking the medication suddenly; instead, reduce the dosage gradually to avoid retention of sodium, chloride, and water.

(5) Regularly check blood electrolytes, liver function and kidney function to avoid electrolyte imbalance, kidney damage, arrhythmia and hepatic encephalopathy. In addition, patients who take potassium-excreting diuretics for a long time can pay attention to proper potassium supplementation, such as using potassium supplement salts and eating potassium-rich foods such as bananas, citrus fruits, potatoes, and rapeseed.

Figure 2 Copyright image, no permission to reprint

4. Why is it necessary to accurately record urine volume when using diuretics?

The use of diuretics may cause adverse reactions such as water and electrolyte imbalance, insufficient effective circulating blood volume, and even induce hepatic encephalopathy. The doctor will adjust the type and dosage of diuretics in a timely manner according to the patient's urine volume changes and provide accurate treatment. Therefore, patients need to accurately record their urine volume.