The medical treatment of
ascites in
cirrhosis is based on
sodium restriction and the administration of
diuretics. Because the natriuretic potency of
spironolactone is greater than that of
loop diuretics (i.e.,
furosemide) in patients with marked
sodium retention,
spironolactone is the basic
drug for the treatment of
ascites. The simultaneous administration of
spironolactone and
furosemide increases the
natriuretic effect of each
drug and diminishes their effects on
potassium metabolism. Recent studies indicate that large-volume paracentesis associated with intravenous
albumin infusion is more effective than
diuretic therapy in eliminating the ascitic fluid; is associated with a lower incidence of complications (
hepatic encephalopathy, renal impairment, and
hyponatremia); and considerably reduces the duration of
hospital stay. Therapeutic paracentesis associated with intravenous
albumin infusion is therefore the treatment of choice for cirrhotic patients with tense
ascites. The mobilization of the ascitic fluid by paracentesis without plasma volume expansion is constantly associated with a deterioration of effective circulating blood volume and may induce renal impairment and severe
hyponatremia.
Dextran 70 and
polygeline appear as effective as
albumin in preventing these abnormalities. Cirrhotic patients treated with paracentesis require the administration of
diuretics to avoid reaccumulation of
ascites.
Peritoneovenous shunt, a
prosthesis capable to correct most abnormalities involved in the accumulation of fluid in the abdominal cavity, is an effective treatment of
ascites in
cirrhosis. It is especially indicated in patients who do not respond to
diuretics and develop repeated episodes of
ascites despite adequate treatment. The use of peritoneovenous shunting is limited by the high incidence of complications induced by the procedure, however. In addition, approximately 40% of patients develop an obstruction of the
prosthesis within the first postoperative year.