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Management of ascites and hepatic hydrothorax

https://doi.org/10.1016/j.bpg.2006.07.012Get rights and content

The natural course of patients with cirrhosis is frequently complicated by the accumulation of fluid in the peritoneal or pleural cavities and interstitial tissue. Functional renal abnormalities that occur as a consequence of decreased effective arterial blood volume are responsible for fluid accumulation in the form of ascites and hepatic hydrothorax. Ascites is the most common complication of cirrhosis and poses an increased risk for infections, renal failure and mortality. Patients have a poor prognosis and it is estimated that nearly half will die in approximately 2 years without liver transplantation. Hepatic hydrothorax is defined as a pleural effusion greater than 500 mL (mostly right-sided) in patients with cirrhosis without cardiopulmonary disease; the estimated prevalence is approximately 5–10%. Liver transplantation is the most definitive cure for both conditions in those patients that are suitable candidates. However, the mainstay of therapy for minimizing fluid accumulation in both conditions includes sodium restriction and administration of diuretics. This article reviews the most current concepts of pathogenesis, clinical findings, diagnosis, and treatment of these complications of cirrhosis.

Section snippets

ASCITES

Ascites is defined as the accumulation of free fluid in the peritoneal cavity. This entity was first described by the ancient Egyptians and Greeks. In 300 BC, Erasitratus of Cappadoccia described cirrhosis as a risk factor for the formation of ascites. Ludwig van Beethoven is one of the most celebrated figures who suffered with ascites and cirrhosis. He was treated with serial, large-volume paracentesis.1

The most common cause of ascites is portal hypertension secondary to cirrhosis, which

DILUTIONAL HYPONATRAEMIA

Dilutional hyponatraemia in cirrhotic patients is defined as serum sodium <130 mEq/L.49 This type of hyponatraemia is usually caused by an inability of the kidneys to excrete solute free water and occurs in the setting of increased total-body water and dilution of extracellular fluid volume. It is associated with sodium retention and increased total-body sodium and should be distinguished from true hyponatraemia caused by sodium depletion, which although less common can develop in cirrhotic

HEPATIC HYDROTHORAX

Hepatic hydrothorax is a relatively uncommon complication of end-stage liver with an estimated prevalence among cirrhotic patients of 5–10%.56, 57 Despite numerous case reports describing clinical features and treatments for hepatic hydrothorax, current knowledge of this complication of cirrhosis is limited.

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