P: Cirrhotic patients with refractory ascites who have hepatic encephalopathy and are not candidates for TIPS or liver transplant

I: Indwelling drainage catheter

C: Large volume paracentesis

O: Decrease in morbidity, complications of repeated LVP/TP and cost

Clinical Question:

Does the use of a permanent indwelling catheter for cirrhotic patients with refractory ascites improve patient palliation while reducing costs and complications?

Evidenced-Based Source:

J Palliat Med. 2003 Oct;6(5):787-91.

Management of intractable, cirrhotic ascites with an indwelling drainage catheter.

Reisfield GM, Wilson GR.

Department of Community Health and Family Medicine, University of Florida Health Science Center-Jacksonville, Florida 32209, USA. gary.reisfield@jax.ufl.edu
PMID: 14622465 [PubMed - indexed for MEDLINE]

World J Gastroenterol. 2009 Jan 7;15(1):67-80.

Evaluation and management of patients with refractory ascites.

Senousy BE, Draganov PV.

Department of Gastroenterology, Hepatology and Nutrition, University of Florida, 1600 SW Archer Rd, Room HD 602, PO Box 100214 Gainesville, Florida 32610, United States. dragapv@medicine.ufl.edu.

Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis (LVP) and transjugular intrahepatic portasystemic stent-shunt (TIPS) are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morbidity and mortality (most surgical options) rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician.

PMID: 19115470 [PubMed - in process]

Key Points:

  • Refractory ascites can cause debilitating symptoms such as orthopnea, dyspnea on exertion or at rest, easy fatigability, abdominal discomfort, anorexia, N/V and severe impairment in quality of life

  • Development of ascites signifies a poor prognosis in cirrhotic patients witha mortality rate of >50% at 6 months

  • Suspect refractory ascites in patients who become non-responsive to diuretics

  • Evalute for liver transplant. If not a candidate and pt requires >3 taps/month while compliant of diet and meds, consider TIPS

  • Requirement for TIPS: CPS<12, MELD<18, <70 yeats old, no hepatic encephalopathy, no cardiopulmonary disease

  • LVP/TP currently the first line therapy for these patients

  • LVP/TP are effective but ascites recurs and requires frequent repeated procedures which are a hardship for patient and family and can leade to infection, hematoperitoneum and bowel perforation

  • Although not fully researched, peritoneal catheter placement in cirrhotic patients with refractory ascites appears to be a novel approach in palliative care for end stage liver disease