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BackTable / VI / Article
Portal Hypertension and Ascites Management
Quynh-Anh Dang • Jun 14, 2021 • 365 hits
We invited hepatologist Dr. Parvez Mantry to share his insights on different methods of portal hypertension and ascites management and treatment modifications. Portal hypertension and ascites are complications of chronic liver disease. These complications arise from loss of liver architecture and liver synthetic dysfunction, and they are ubiquitous in cirrhotic patients. Due to the long-term nature of this disease, providers may have to remain flexible with treatment approaches and collaborate with other providers over the course of illness. This article is the second part of our series on portal hypertension and ascites.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• Portal hypertension and ascites management can be approached through a number of methods, depending on the degree of ascites, liver disease progression, and transplant eligibility. For mild and moderate ascites, Dr. Mantry will usually prescribe diuretics. For severe ascites, paracentesis, a TIPS procedure, or a transplant may be needed.
• Prescribing diuretics for ascites may involve periodic adjustments to the dosage level. Initially, Dr. Mantry will see his patients on a weekly or bi-weekly basis until he sees that the patient is tolerating the regimen well.
• With paracentesis, Dr. Mantry focuses on kidney function to determine the ascites drainage maximum volume. He will also give 10 grams of intravenous albumin per liter of fluid removed when removing more than 4L of fluid.
• If the patient is struggling with leakage from the paracentesis site, there are multiple ways to mitigate this, including Dermabond, cerclage stitch, colostomy bag, and repeat paracentesis.
• Communication with other specialists and family members is crucial when a patient is awaiting liver transplantation.
Table of Contents
(1) Portal Hypertension and Ascites Management Strategies
(2) Modifying Diuretics for Ascites Management
(3) Paracentesis and Intravenous Albumin for Ascites Management
(4) Advice for Providers and Patients Awaiting Liver Transplant
Portal Hypertension and Ascites Management Strategies
Dr. Mantry describes the prevalence of portal hypertension and ascites in his cirrhotic patients and discusses management and treatment techniques. Then, he outlines two different degrees of ascites and his use of diuretics and paracentesis if needed. In patients with refractory ascites (ascites that recurs shortly after paracentesis), other methods of treatment like transjugular intrahepatic portosystemic shunts (TIPS) and transplant may be required.
[Dr. Christopher Beck]
Let's talk a little bit about portal hypertension and ascites management. How common are portal hypertension and ascites in your patient population?
[Dr. Parvez Mantry]
Pretty much every patient with cirrhosis, at some point in their lifespan, will develop portal hypertension if they already don't have it. Ascites is the most common and the most ominous sign of cirrhosis and liver failure, primarily because it is a manifestation of both liver synthetic dysfunction and portal hypertension. It takes two of those underlying conditions for the patient to develop ascites.
[Dr. Christopher Beck]
Let's talk about some of the treatments for ascites. From an interventional radiologist's perspective, I always think of three things: things: diuretics, paracentesis, and the TIPS procedure. Can you speak about how you approach the management of patients with ascites?
[Dr. Parvez Mantry]
When patients have mild or moderate ascites (which means that I can feel the ascites, but their belly is not tense) and they have a lot of pedal edema, I will usually start them with a combination of furosemide and spironolactone. With a loop diuretic, potassium-sparing diuretic, and salt restriction, we may be able to manage the ascites 70% to 80% of the time.
In another scenario, somebody comes with tense ascites, their abdominal wall is stretched, their umbilicus is everted, and they are usually very uncomfortable. In addition to starting them on diuretics, I will usually perform a paracentesis in the office and remove 8-10 liters of fluid and give intravenous albumin.
Patients who require weekly paracentesis, with livers that are still salvageable (measured by their MELD score), are suitable candidates for placement of a transjugular intrahepatic portosystemic shunt (TIPS).
We also make the assessment of whether the patient is a transplant candidate. If they are, and they are eligible, we put them on the list. We have some experimental therapies coming for ascites management as well.
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Modifying Diuretics for Ascites Management
During a patient’s diuretics regimen, Dr. Mantry monitors glomerular filtration rate, potassium, sodium, creatinine, weight, and pedal edema. He emphasizes that diuretics management is an ongoing process and dosing should be constantly monitored and adjusted accordingly. The frequency of these changes depends on whether the patient is an outpatient or an inpatient.
[Dr. Christopher Beck]
I want to talk more about diuretics. Let’s assume renal function stays stable, and you want to increase diuretics. How often do you tweak the diuretics to get the level of ascites managed appropriately? How often are you seeing these patients to change their diuretics regimens?
[Dr. Parvez Mantry]
Initially, I see them every one or two weeks. Some patients are very sensitive to diuretics when we start them off. We want to make sure that their potassium, sodium and creatine are okay. Usually, we do not escalate diuretics by more than one week at a time, unless they're in-patients. If they are in-patients, we can make those changes on a daily basis because we are monitoring them so closely. Otherwise, it is one to two weeks. We look at their weight and pedal edema. For instance, if the pedal edema is gone but the ascites is still large, we are very wary of increasing diuretics because those patients are at a higher risk of developing hepatorenal syndrome. Those patients also tend to run a low borderline blood pressure. You have to be very alert and very mindful of everything that's going on around them, because diuretics are clearly a very double-edged sword. They are very helpful, but slight mismanagement of them can be very unforgiving.
[Dr. Christopher Beck]
What about patients who do not tolerate their original diuretic regime very well? If you see bumps in their creatinine and a decrease in their GFR, can you back off their diuretics? Are there opportunities to work back up to increasing those diuretics after you've had some time to establish a new equilibrium?
[Dr. Parvez Mantry]
Most certainly. We play this ping pong game with diuretics all the time. One week, I may scale them down, and in the next week, I may go back up. The kidney function is very, very critical in cirrhotic patients because once hepatorenal syndrome sets in, if we are not very mindful of making these adjustments, these patients can go downhill very, very rapidly. We make changes all the time.
Sometimes, if the creatinine has gone up rapidly, I will put them in the hospital and give them some intravenous albumin. This increases the colloid oncotic pressure. By doing that, renal perfusion improves and we are able to reset the diuretics to a point where these patients can effectively lose that extra amount of extracellular fluid.
Paracentesis and Intravenous Albumin for Ascites Management
Paracentesis is an ascites drainage procedure. Dr. Mantry shares his guidelines on ascites drainage maximum volume. He also discusses administration of intravenous albumin after paracentesis and troubleshooting advice for post-procedure leakage.
[Dr. Christopher Beck]
With paracentesis, is there a limit to how much volume you will take off for a patient?
[Dr. Parvez Mantry]
It totally depends. The most important determinant is kidney function. If the GFR is less than 30, then we typically do not want to remove more than 6 liters of fluid, and we will always give them intravenous albumin. In our practice, as well as that of our IR colleagues, if anybody requires more than 4 liters of paracentesis, we give them intravenous albumin: 10 gram per liter of fluid removed. This is to avoid a condition called post-paracentesis circulatory dysfunction, which leads to kidney failure and can be very catastrophic. That's the rule of thumb. In patients who have normal kidney function and have a normal blood pressure, I could potentially remove up to 15L of fluid, as long as I'm very particular and diligent about the albumin. If I remove 15L of fluid, I give them 150 grams of IV albumin.
[Dr. Christopher Beck]
Actually, I did want to drill down on your protocol for albumin. You gave a good example with removing 15 liters, but I just want to repeat it with some numbers that might be a little more reasonable for people to follow. If you remove 6 liters, you're going to give 60 grams of albumin?
[Dr. Parvez Mantry]
Correct.
[Dr. Christopher Beck]
Okay. And then anything below 4 liters doesn't warrant albumin?
[Dr. Parvez Mantry]
Anything below 4 liters, you can get away without use of IV albumin. You won't go wrong with IV albumin, but there are logistics that have to be taken into consideration: Does the patient have an IV? What would the albumin cost? However, for the overwhelming majority of the time, we will give IV albumin during the paracentesis.
[Dr. Christopher Beck]
Do you have any troubleshooting tips for patients who have a lot of leakage from the stick site, after they undergo paracentesis?
[Dr. Parvez Mantry]
That's a great question. In fact, just yesterday, I was writing a new research project on this issue. It is a very common problem. There are four ways to mitigate it.
First, we use Dermabond, which we found is very helpful. It is very minimally irritating to the skin.
Second, we can do a cerclage stitch, if it is a really big opening. Our interventional radiologists do that a lot.
Third, if these patients are not in a tertiary referral center, they can be sent to one. But until they can come and see me at the tertiary center, I'll just ask them to put a colostomy bag.
Fourth, the best treatment when these patients have a large amount of ascites and leakage is to do another paracentesis because the leakage is due to excessive pressure in the abdomen. If you can tap them dry, then the leakage will automatically go away.
Advice for Providers and Patients Awaiting Liver Transplant
Transplant waitlist management is a significant aspect of chronic liver diseases. Beyond portal hypertension and ascites management within his practice, Dr. Mantry also recognizes the importance of reaching out for provider collaboration and patient/family support.
[Dr. Christopher Beck]
Is there any advice you can give to physicians in the community or people who are not at transplant centers? Can you talk about a way to plug patients in with a local transplant center?
[Dr. Parvez Mantry]
Absolutely. I think it's really important to have a relationship with your transplant center because patients with liver disease can deteriorate very rapidly and the deterioration can often be catastrophic. Folks at transplant centers like ours usually want to have very close community liaisons with these providers, so we can bring them at the drop of a hat, either inpatient or outpatient. We have satellite locations all over the metroplex to help us serve these patients.
The key thing is if your patient has started showing signs of hepatic decompensation, which are ascites, pedal edema, one episode of bleeding from varices, hepatic, encephalopathy, muscle wasting, or jaundice, those are the signs that should alert you to get them plugged in into your closest liver transplant center.
Having a family support system is very important. Transplant is not something that can be done by the patients alone. I tell my patients, “Don't fight this battle on your own, inform your close family members and see what help you can mobilize from them.” And then finally, I advise them to keep a close network of doctors and stay in touch with their primary care physician, gastroenterologist, hepatologist, and transplant center. This helps us communicate and tie all the loose ends well.
Podcast Contributors
Dr. Parvez Mantry
Dr. Parvez Mantry is the Medical Director of the Liver Institute Research and the Hepatobiliary Tumor Program at the Methodist Health System in Dallas, Texas.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, May 17). Ep. 127 – Portal Hypertension and Ascites Management [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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