Treatment of Complications:

Treatment of Ascites

First-line treatment of patients with ascites (fluid accumulation in the abdomen) involves:

• Dietary salt restriction (no more than 1,500 mg/day of sodium)
• Drug treatment with diuretics, usually spironolactone (Aldactone) and furosemide (Lasix).
• Complete abstention from alcohol
• Fluid restriction is usually not necessary unless sodium levels in the blood are low.

Treatment for Recurring or Refractory Ascites. Patients with ascites that does not respond to standard diuretics after a month (refractory ascites) may require procedures to reduce fluid:

• Large-volume paracentesis may be used for ascites refractory to medical treatment or when complications are present. It involves removing large volumes of fluid through a tube in the abdomen.
• Transjugular intrahepatic portosystemic shunt (TIPS) uses a stent placed in veins in the middle of the liver to keep open a passage connecting the hepatic and portal veins. In the procedure, a long needle is inserted into the jugular vein in the neck and passed down through the vena cava, a large vein that conducts blood back to the heart. The surgeon makes an incision in the hepatic vein in the liver and creates a connection to the portal vein. The stent is inserted into this connecting vein to act as a shunt and reroute blood around the scarred liver. TIPS is used for patients with refractory ascites who may require a transplant. In general, TIPS should be a second-line option for ascites that does not respond to diuretics.
• Peritoneovenous shunting is an older, more invasive, procedure involving insertion of a tube under the skin that routes the fluid from the abdomen into the jugular vein. The procedure can have serious complications, including infection, blood clots, encephalopathy, and rupture of blood vessels in the esophagus. It is now generally reserved for patients who are not candidates for paracentesis, TIPS, or liver transplantation.

Treatment of Spontaneous Bacterial Peritonitis

Patients with ascites who have high white blood cell counts should receive intravenous antibiotic therapy (usually cefotaxime). Patients who have had an episode of spontaneous bacterial peritonitis are treated with long-term antibiotic therapy of norfloxacin (Noroxin) or trimethoprim/sulfamethoxazole (such as Bactrim or Septra) to prevent further infection.

Treatment of Hepatorenal Syndrome

Hepatorenal syndrome can occur in patients with ascites. This is a life-threatening condition in which the kidneys fail in trying to compensate for altered blood flow in the liver. Patients with hepatorenal syndrome are treated with intravenous infusion of albumin. Drug therapy includes oral midodrine (ProAmatine) and octreotide (Sandostatin). Studies suggest that the vasoconstrictor drug terlipressin may be an effective treatment in combination with albumin for hepatorenal syndrome.

Treatment of Hepatic Encephalopathy

The first step in managing encephalopathy (damage to the brain) is to treat any precipitating cause, such as:

• High ammonia levels
• Bleeding
• Low oxygen
• Dehydration
• Infection
• Use of sedatives

A protein-restricted diet may be used to lower ammonia production. The laxative lactulose is given as a syrup or enema is given to empty the bowels and to help improve mental status. The antibiotic neomycin may be added for patients who do not improve with lactulose alone. Rifaximin (Xifaxan), another antibiotic, was approved in 2005 for treatment of hepatic encephalopathy.

Treatment of Variceal Bleeding

Primary Prevention. Nonselective beta-blocker drugs, which are used to treat high blood pressure, are given to reduce portal hypertension (high pressure in the portal vein) and prevent variceal bleeding in patients with cirrhosis who have small varices and risk factors for hemorrhage. Propanolol (Inderal) or nadolol (Corgard) are the standard beta-blockers used for variceal prevention.

Patients with medium-to-large varices that have not bled but have a high risk for hemorrhage may be treated with either these beta-blocker drugs, or with a surgical procedure called endoscopic variceal ligation (EVL). EVL is also called band ligation. Endoscopic procedures use a tube inserted down through the esophagus, which contains microcameras and tiny instruments. In EVL, latex bands are wrapped around the bleeding varices, which shut off the blood supply.

EVL as preventive therapy may also be considered for patients who are not appropriate candidates for beta-blocker therapy. The American College of Gastroenterology and the American Association for the Study of Liver Diseases does not recommend other types of therapy such as nitrate drugs, shunts, or sclerotherapy as primary prevention of variceal bleeding.

Treatment. Variceal hemorrhage is an emergency situation. The first step is to immediately achieve normal blood clotting (hemostasis) in order to stop the current bleeding episode. Patients almost always need blood transfusions.

The primary treatment for variceal hemorrhage is drug therapy with ocreotide (Sandostatin). This drug is given for 3 - 5 days after a diagnosis is made, as this time period poses the greatest risk for rebleeding. Drug therapy is combined with endoscopic therapy. Endoscopic variceal ligation (band ligation) is usually the preferred method. An alternative procedure is endoscopic sclerotherapy. In endoscopic sclerotherapy, the endoscopic tube is inserted through the mouth and a sclerosant (a solution that toughens the tissue around the variceal blood vessels) is injected to stop the bleeding.

If these treatments do not successfully control variceal bleeding, or bleeding recurs, a transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed. (For more information on TIPS, see Treatment of Ascites above.) TIPS is not useful as the first choice for stopping an initial bleeding episode or for preventing rebleeding since it poses a high risk for encephalopathy.

Another procedure, called balloon tamponade, may be used to temporarily control bleeding prior to the TIPS procedure. Balloon tamponade has been available for years, but it is now used only for bleeding that cannot be controlled by drugs or endoscopy. It uses a tube inserted through the nose and down through the esophagus until it reaches the upper part of the stomach. A balloon at the tube's end is inflated and positioned tightly against the esophageal wall. It is usually deflated in about 24 hours. Balloon tamponade poses a risk for serious and potentially lethal complications, the most dangerous being rupture of the esophagus. For this reason, balloon tamponade is used only for patients with uncontrollable bleeding.

Secondary Prevention. Patients who survive an episode of variceal bleeding need to be treated with drugs to prevent bleeding recurrence. Patients are prescribed either a combination of a nitrate drug [such as isosorbide (Ismo), which is used to treat angina] and a nonselective beta-blocker (propanolol or nadolol) or a beta-blocker alone. Patients are also given several sessions of endoscopic variceal ligation over the course of several months. The TIPS procedure may be recommended for patients who experience recurrent bleeding despite drug and endoscopic therapy.