Explore the vast range of titles available.

Background Large-volume total paracentesis may result in paracentesis-induced circulatory dysfunction, which is associated with poor outcomes. Aims To explore the short- and long-term effects of paracentesis-induced circulatory dysfunction on systemic hemodynamics, renal function and other cirrhosis-related complications in patients with refractory ascites, following subtotal large-volume paracentesis. Methods Patients with cirrhosis and refractory ascites without renal dysfunction had systemic hemodynamics, renal function, and neurohormones (plasma active renin, aldosterone, norepinephrine and angiotensin II) measured pre- and 6 days post-paracentesis. Paracentesis was limited to ≤8 L with 6–8 g of albumin per liter ascites drained. Patients were followed up until transjugular intrahepatic portosystemic shunt insertion, liver transplantation, or death. Paracentesis-induced circulatory dysfunction was defined as >50 % increase in plasma active renin 6 days post-paracentesis. Results Fifty-seven patients (mean age 59.0 ± 9.4 years) had mean 6.8 ± 1.8 L of ascites removed with 9 ± 3 g of albumin given/L of ascites drained. Patients were followed up for 715 ± 104 days. Twenty-three patients (40.4 %) developed paracentesis-induced circulatory dysfunction with unchanged serum creatinine on day six, despite worsening of hemodynamics (mean arterial pressure 90 ± 10 mmHg at baseline vs. 84 ± 8 mmHg on day six, p  < 0.05). Similar hemodynamic changes were observed among patients without paracentesis-induced circulatory dysfunction. There was no significant difference in the long-term renal function or cirrhosis-related complications between the groups. Conclusion The occurrence of paracentesis-induced circulatory dysfunction, as defined by plasma active renin, may not have a significant short- and long-term impact on renal function or cirrhosis-related complications in patients with refractory ascites who undergo subtotal paracentesis with albumin infusion.

Purpose of Review Despite refractory ascites (RA) due to cirrhosis having a median transplant-free survival of 6–12 months, palliative care (PC) input remains uncertain. We aimed to review the existing literature on clinical outcomes in cirrhosis-related RA and report the findings of a single-centre retrospective cohort study with a special focus on linkage to PC in this cohort of patients. Recent Findings Our study and subsequent literature review confirm the high mortality associated with cirrhosis-related RA (19–55% 1-year mortality) with only a minority of patients receiving curative options (3–23%). Despite this, in our study only a minority of patients (33%) were referred to PC. None of the studies identified in the scoping review makes any references to palliative care use. Summary Our own data and a literature review confirm that, despite high mortality, only a minority with RA due to cirrhosis are referred for specialist PC input and often too late in their disease trajectory. Future research should focus on patient-centred outcomes in this cohort of patients where optimising quality-of-life and facilitating advanced care planning should be a priority.

Background: Large-volume paracentesis (LVP) of the peritoneal and pleural cavities is a common diagnostic and therapeutic intervention in patients with liver cirrhosis or advanced heart failure, which are both frequently associated with ascites or pleural effusion. Although generally regarded as a low-risk procedure, LVP may lead to complications such as intrapleural or intra-abdominal hemorrhage, and more commonly abdominal wall bleeding, as well as organ puncture and infection. Performing LVP in patients with coagulopathy or bleeding disorders, whether disease-related or due to anticoagulant therapy, poses a significant clinical challenge. The safety thresholds for such procedures remain inconsistent, and strategies to mitigate bleeding risk are still debated among professional societies. Methods: This review integrates institutional experience with a systematic synthesis of the current international literature to identify the safest and most effective approaches for performing LVP in patients with coagulopathy. The methodological framework included a comparative analysis of existing professional guidelines, as well as a critical evaluation of published evidence regarding risk stratification, pre-procedural correction strategies, and peri-procedural management. The evidence grading was assessed with the STAIR checklist. Results: Analysis of the evidence revealed substantial variability among professional recommendations concerning acceptable platelet and INR thresholds, as well as differing approaches to the management of patients receiving anticoagulant or antiplatelet therapy. Despite these discrepancies, the aggregated data support the conclusion that LVP can be performed safely in most patients with mild-to-moderate coagulopathy, provided that appropriate risk assessment and technical precautions are implemented. Conclusions: The resulting evidence-informed suggestions provide a practical framework for clinicians performing LVP in high-risk patients. By emphasizing systematic pre-procedural evaluation, individualized management of coagulopathy, and adherence to standardized procedural techniques, this work aims to promote safety, consistency, and confidence in the performance of large-volume paracentesis across diverse clinical settings.

Background Transjugular intrahepatic portosystemic shunt (TIPS) has recently been reported to be effective in the treatment of cirrhotic patients with refractory ascites. However, the clinical utility of TIPS in the subset of refractory ascitic patients with good hepatic and renal function is uncertain. The aim of this study was to compare the efficacy of TIPS to that of large-volume paracentesis in cirrhotic patients with refractory ascites who have good hepatic and renal function. Methods Sixty cirrhotic patients with refractory ascites who presented with a Child-Pugh score of <11, serum bilirubin of <3 mg/dl and creatinine of <1.9 mg/dl were assigned randomly to TIPS (n = 30) or large-volume paracentesis plus albumin (n = 30). The primary endpoint was survival. The secondary endpoints were response to treatment and development of hepatic encephalopathy. Results The baseline characteristics were similar in the two groups. Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period. The cumulative probabilities of survival at 1 and 2 years were 80 and 64% in the TIPS group and 49 and 35% in the paracentesis group (p < 0.005). TIPS was significantly superior to paracentesis in the control of ascites (p < 0.005). Treatment failure was more frequent in the paracentesis group, whereas the frequency of hepatic encephalopathy was greater in the TIPS group. Conclusions In cirrhotic patients with refractory ascites who have good hepatic and renal function, TIPS improves survival and provides better control of ascites than large-volume paracentesis.

The development and progression of ascites represent a crucial event in the natural history of patients with cirrhosis, predisposing them to other complications and carrying a heavy impact on prognosis. The current standard of care for the management of ascites relies on various combinations of diuretics and large-volume paracenteses. Periodic long-term albumin infusions on top of diuretics have been recently shown to greatly facilitate the management of ascites. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS), an artificial connection between the portal and caval systems, is indicated to treat patients with refractory ascites. TIPS acts to decrease portal hypertension, thus targeting an upstream event in the pathophysiological cascade of cirrhosis decompensation. Available evidence shows a significant benefit on ascites control/resolution, with less clear results on patient survival. Patient selection plays a crucial role in obtaining better clinical responses and avoiding TIPS-related adverse events, the most important of which are hepatic encephalopathy, cardiac overload and failure, and liver failure. At the same time, some recent technical evolutions of available stents appear promising but deserve further investigations. Future challenges and perspectives include (i) identifying the features for selecting the ideal candidate to TIPS; (ii) recognizing the better timing for TIPS placement; and (iii) understanding the most appropriate role of TIPS within the framework of all other available treatments for the management of patients with decompensated cirrhosis.

Ascites is one of the main complications of advanced liver cirrhosis. It is defined as a pathological accumulation if free fluid in the peritoneal cavity. This review summarized the effectiveness of other alternative drugs.

Ascites is a dreadful complication of liver cirrhosis associated with short survival. Large volume paracentesis (LVP) is used to treat tense or refractory ascites. Paracentesis induced circulatory dysfunction (PICD) develops if no plasma expanders are given with ominous complications. To study the effect of ascites flow rate on PICD development. Sixty patients with cirrhosis and tense ascites underwent LVP of 8 L were randomized into 3 equal groups of different flow rate extraction; group I (80 mL/minute), group II (180 mL/minute) and group III (270 mL/minute). Plasma renin activity (PRA) was measured baseline and on day six. PICD was defined as increase in PRA >50% of the pretreatment value. In group I through 3; the mean age was (52.5±9.4 vs. 56.4±8.5 vs. 55.8±7.1 years; P>0.05), mean arterial pressure (81.4±5.6 vs. 81.5±7 vs. 79.5±7.2 mmHg; P>0.05), MELD (17.6±4.1 vs. 15.8±4.1 vs. 14.7±4.5). Baseline PRA was comparable (1,366.0±1244.9 vs. 1,151.3±1,444.8 vs. 951.9±1,088 pg/mL; P>0.05). There was no statistically significant (P>0.05) flow mediated changes (Δ) of creatinine (0.23±0.27 vs. 0.38±0.33 vs. 0.26±0.18 mg/dL), MELD (1.25±5.72 vs. 1.70±2.18 vs. 1.45±2.21) or PRA (450.93±614.10 vs. 394.61±954.64 vs. 629.51±1,116.46 pg/mL). PICD was detected in a similar frequency in the three groups (P>0.05). On univariate logistic analysis only female sex was a fairly significant PICD predictor (Wald 3.85, odds ratio 3.14; P=0.05). The ascites flow rate does not correlate with PICD development.

Large-volume paracentesis (LVP) is a main pillar in treating patients with tense ascites. Without plasma expanders use, paracentesis-induced circulatory dysfunction (PICD) is a common complication with decreased survival. The aim was to compare low-dose albumin (2 g/L ascitic fluid removed n = 85) with standard-dose albumin (6 g/L ascitic fluid removed, n = 25) for prevention of PICD. Liver function tests, urea, creatinine, CBC, and abdominal ultrasonography were done. Plasma renin activity (PRA) was measured at baseline and on the 6th day post-LVP. The delta change ([DELTA]) = day 6 variable minus baseline variable value. PICD was defined as increase in PRA of > 50% of the baseline value. Low-dose albumin infusion is comparable to the standard-dose albumin for the prevention of PICD.

Among the various risky complications of liver cirrhosis, refractory ascites is associated with poor survival of cirrhotics and persistently worsens their quality of life (QOL). Major clinical guidelines worldwide define refractory ascites as ascites that cannot be managed by medical therapy either because of a lack of response to maximum doses of diuretics or because patients develop complications related to diuretic therapy that preclude the use of an effective dose of diuretics. Due to the difficulty in receiving a liver transplantation (LT), the ultimate solution for refractory ascites, most cirrhotic patients have selected the palliative therapy such as repeated serial paracentesis, transjugular intrahepatic portosystemic shunt, or peritoneovenous shunt to improve their QOL. During the past several decades, new interventions and methodologies, such as indwelling peritoneal catheter, peritoneal-urinary drainage, and cell-free and concentrated ascites reinfusion therapy, have been introduced. In addition, new medical treatments with vasoconstrictors or vasopressin V2 receptor antagonists have been proposed. Both the benefits and risks of these old and new modalities have been extensively studied in relation to the pathophysiological changes in ascites formation. Although the best solution for refractory ascites is to eliminate hepatic failure either by LT or by causal treatment, the selection of the best palliative therapy for individual patients is of utmost importance, aiming at achieving the longest possible, comfortable life. This review briefly summarizes the changing landscape of variable treatment modalities for cirrhotic patients with refractory ascites, aiming at clarifying their possibilities and limitations. Evolving issues with regard to the impact of gut-derived systemic and local infection on the clinical course of cirrhotic patients have paved the way for the development of a new gut microbiome-based therapeutics. Thus, it should be further investigated whether the early therapeutic approach to gut dysbiosis provides a better solution for the management of cirrhotic ascites.

Introduction In most centres including our own, large volume paracentesis (LVP) has traditionally been performed under free drainage. The authors sought to evaluate the safety and efficacy of a low pressure suction system during its introduction to their gastroenterology day ward. Methods A low pressure suction controller was plugged in to a standard wall suction point, and adjusted to provide 100 mm Hg of suction. Ascites was drained using either a Safe-T-Centesis or Bonanno catheter and collected in a Vacsax suction carousel. As per our local protocol, 20 g of salt poor albumin was given per 3 l of ascites drained. Blood pressure and heart rate were recorded every 30 min. The total volume of fluid, duration of drainage and any complications were recorded. Flow rate was then calculated in l/min. Similar data was also collected from patients undergoing free drainage paracentesis, which was used while all nursing staff were familiarised with the suction. Results 14 patients (9 male, 5 female) with large volume ascites underwent 46 episodes of LVP (29 cases ALD, 11 cases NAFLD, 6 malignant ascites – was albumin given to these malignant patients?). 27 LVPs were performed under suction and 19 under free drainage. Compared to free drainage procedures, suction LVPs took significantly less time (mean duration 233.9±59.1 vs 279.7±61.1 min, p=0.01). Suction LVPs drained similar volumes (10.45±4.1 vs 9.6±3.8 l, NS) and achieved similar mean flow rates (0.048±0.021 vs 0.035±0.014 l/min, NS). One patient undergoing suction LVP developed transient mild abdominal pain that settled spontaneously. No patients in either group experienced significant complications. Conclusion Low pressure suction paracentesis is significantly faster than free drainage procedures, and can be easily introduced in a day case setting. The benefits to patient and nursing time combined with excellent safety have led the authors to continue low pressure LVP as standard care on their gastroenterology day ward.