From the Guidelines
The presence of shifting dullness in a patient with ascites is a significant clinical finding that warrants further evaluation and management, as outlined in the guidelines for the management of ascites in cirrhosis 1. The guidelines emphasize the importance of testing the ascitic fluid for protein and white cell count to differentiate the cause of ascites and to rule out infection 1. In patients with cirrhosis and ascites, the initial treatment involves medication, commonly known as 'water tablets' (diuretics), which are begun at a small dose and gradually increased until the ascites is treated 1. However, as the liver disease progresses, the ascites may no longer respond to medication, requiring alternative treatments such as repeated hospital drainage or placement of a transjugular intrahepatic portosystemic shunt (TIPSS) 1. Key points to consider in the management of ascites include:
- Testing the ascitic fluid for protein and white cell count
- Initial treatment with diuretics
- Monitoring for side effects of diuretics
- Consideration of alternative treatments such as TIPSS or repeated hospital drainage for refractory ascites
- The importance of controlling salt intake, with no more than 5g of salt per day 1. It is essential to note that the only curative option for untreatable ascites is liver transplantation, and medical care should focus on controlling the ascites symptoms if the patient is not suitable for liver transplantation 1.
From the Research
Diagnosis and Physical Examination
- The physical examination of a patient with ascites may reveal shifting dullness, a fluid wave, and peripheral edema 2.
- Shifting dullness is a sign that can be detected during physical examination to diagnose ascites, especially in patients with large amounts of ascitic fluid 2.
- Ultrasound examination is useful in establishing the diagnosis and in locating the optimal site for paracentesis 2.
Treatment and Management
- The treatment of ascites is directed toward alleviating the underlying cause of ascites and reducing symptoms 2.
- Restriction of salt intake to 2 g per day is usually advised, and most patients require diuretic therapy 2, 3.
- Spironolactone is the usual first-choice agent, and it may be combined with furosemide in selected patients 2, 3, 4, 5.
- Large-volume paracentesis (LVP) provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients 6, 5.
- LVP is the treatment of choice for cirrhotic patients with tense ascites, and it is associated with a lower incidence of complications compared to diuretic therapy 5.
Complications and Prognosis
- The development of ascites indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate 6, 3.
- Refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment, and it has a poor prognosis 3.
- Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites, and it may precipitate hepatorenal syndrome 6.
- The overall mortality rate from an episode of SBP is approximately 20%, and the 1-year mortality rate approaches 70% after an episode of SBP 6.