Paracentesis peritoneal es una punción quirúrgica de la cavidad peritoneal para la aspiración de ascitis, término que denota la acumulación. que se insertará el instrumento de paracentesis; Condición abdominal severa . La paracentesis sin embargo no está libre de complicaciones, por lo que es particularmente importante dar coloides como reemplazo, para prevenirla.
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This revision was aimed to report the evidences on the treatment of patients with cirrhosis and refractory ascites. Mainly, we wished to explore which of the predicting variables could be used to prefer large-volume paracentesis or TIPS.
During the natural co,plicaciones of cirrhosis an increased renal reabsorption of co,plicaciones and water which generates edema is a serious complication of portal hypertension. In fact, the first episode of ascites is a turning point of the disease which announces the risk of other complications of cirrhosis such as renal failure, hyponatremia, encephalopathy, variceal bleeding and bacterial infections.
All these complications develop because of two pathophysiological events. First, the increase of portal pressure causes peritoneal accumulation of fluids ascites in consequence of a high filtration rate at the sinusoidal level.
Second, the peripheral release of potent vasodilators, mainly in the splanchnic vascular bed, causes a hyperdynamic circulation compllcaciones high cardiac output and low peripheral resistances.
The excess of vasoconstrictors can be detrimental for the kidney, the brain, and also for the cardiac fibers with an impaired cardiac contractility.
Moreover, patients with cirrhosis and ascites are frequentely complicated by acute episode of bacterial infection. In most patients with cirrhosis and ascites a low sodium diet combined comppicaciones diuretic medications obtains the disappearance of ascites. In these cases the administration of diuretic drugs is insufficient to increase urinary sodium excretion diuretic-resistant ascites or, more often, the diuretic therapy cannot be tolerated because of serious side-effects, such as encephalopathy, hyponatremia, renal failure diuretic intractable ascites.
Recently, the most accepted criteria for defining refractory ascites are an ascites that cannot be mobilized or whose re-accumulation after large-volume paracentesis LVP cannot be prevented by medical therapy.
Requirements for the diagnosis of refractory ascites are: The median survival of patients suffering from refractory ascites is approximately 6 months.
Hence, refractory ascites is per se an indication to liver transplantation but most of such patients do not meet all the criteria to be included in a list of liver transplant. The causes of exclusion are advanced age, relevant comorbidities such as coronaropathy, other cardiac or vascular diseases, cancer. In addition some patients, although affected by a severe liver disease do not rich the threshold to be admitted.
To prevent or delay the occurrence of refractory ascites is a very important clinical issue. Although there are no studies specifically aimed to explore this possibility, it is reasonable that refractory ascites could be prevented by stopping the progression of liver damage, as can be achieved by removing the etiologic factors of liver disease or by reducing the portal pressure.
CAMBIOS CARDIOVASCULARES EN LA CIRROSIS. EL IMPACTO DE LAS COMPLICACIONES Y LOS TRATAMIENTOS
Several strategies to treat refractory ascites have been developed and tested with observational studies, randomized trials, and meta-analysis. LVP with albumin and transjugular intrahepatic portosystemic shunt TIPS are the most used strategies, and they will be specifically discussed. One of the first treatments of refractory ascites was peritoneo-venous shunt or LeVeen shunt. The rationale for using this device is to reduce the volume of ascites with a simultaneous re-expansion of the plasma volume.
However, the success of the peritoneo-venous shunt was counterbalanced by the frequent occurrence of side-effects such as bacterial infections and occlusion of the paracenresis. Moreover, two relevant RCTs demonstrated that the use of LeVeen shunt to treat tense ascites was not superior to the treatment with repeated LVP complicacionez albumin infusion.
A more recent device to treat refractory ascites is Alpha Pump, 16 an implanted pump for the automated low-flow removal of ascites from the peritoneal cavity into the bladder. Alpha Pump, however, is an expensive device whose effects and safety still deserve to be ascertained by RCTs vs.
In the last years, a new family of orally active drugs, vaptansthat increase urine volume by the antagonism of the vasopressin V2 receptors have been tested for the treatment of the syndrome of inappropriate anti-diuretic hormone secretion SIADH.
[Paracentesis as abdominal decompression therapy in neuroblastoma MS with massive hepatomegaly].
These drugs, even if able to enhance solute free-water excretion and increase the serum sodium concentrations, did not demonstrate to be useful in the treatment of patients with refractory ascites.
Indeed, the rapid and complete efficacy in reducing ascites with rare complications made LVP plus albumin the first line of treatment for tense ascites.
It is a hemodynamic derangement with risk of detrimental clinical consequences. This complication oaracentesis often asymptomatic, but sometimes generates renal failure and hyponatremia. Mean survival is shorter in patients who develop PPCD compared to those who do not.
To prevent PPCD an infusion of human albumin at the dose of 7—8 g per liter of fluid tapped is highly recommended. Other rare complications of LVP are intra-abdominal bleeding and bacterial infections.
However, in a series of procedures, De Gottardi et al. Thus, caution should be adopted in patients who has reached these alterations. TIPS is a porto-systemic shunt obtained by an intravascular insertion of a stent bridging a portal branch with an hepatic vein. This procedure causes a fall of portal pressure with reduction of the vascular collateral circulation. A further important effect of TIPS is the increase of central blood volume with potential improvement of renal function.
At today, the main indications for TIPS are: In addition, in patients with advanced cirrhosis and ascites, TIPS can improve the nutritional status by favoring complicacions nitrogen positive balance.
All these complications are rare in expert hands. By contrast, the frequency is higher for apracentesis risks such as hepatic encephalopathy, the occlusion of the stent, hemolytic anemia, cardiac dysfunction. Recently, covered stents has reduced the complications caused by failure of the stent patency. This allows a stable hemodynamic result of the TIPS.
Nevertheless, the risk of hepatic encephalopathy is still high and constitutes one of the most important limit to a larger use of TIPS. Accordingly, a strict selection of candidates could obviate most of such complications. A meta-analyses conducted on four out of five RCTs showed that resolution of refractory ascites was significantly greater pwracentesis patients treated with TIPS but the survival was only marginally better for TIPS patients.
Variables significantly associated with survival were age, serum bilirubin, and serum sodium. Accordingly, patients with refractory ascites showing normal values of these three variables were suggested to be complicacoones optimal candidates to be treated with TIPS. The survival advantage observed in specific subgroups of patients treated with TIPS could be consequence of the low incidence of other complications due to portal hypertension.
Indeed, Gines et al. Notwithstanding, all these advantages should paracentsis weighted with the consistent higher risk of oaracentesis. Another important aspect to be taken into account is the impact of refractory ascites therapy on the quality of life. Moreover, a post hoc analysis from Campbell 27 demonstrated that patients with refractory ascites randomized to TIPS or LVP had similar alterations of their quality of life, due to the greater development of hepatic encephalopathy in paracenesis receiving TIPS and to the more frequent taps in patients treated with LVP.
In conclusion it is important to remember that almost all the clinical observations of this paper come from studies in which bare-stents were used instead of covered-ones. Thus, the comparison between TIPS and LVP should be re-evaluated in the light of the complicacionnes hemodynamic effects achieved by the covered stents.
The authors declare no parafentesis of interest. Therapy of the refractory ascites: Tratamiento de la ascitis refractaria: Vincenzo La MuraFrancesco Salerno. Mainly, we wished to paracenttesis which of the predicting variables could be used to prefer large-volume paracentesis or TIPS.
In addition some patients, although affected by a severe liver disease do not rich the threshold to be admitted. Prevention of refractory ascites To prevent or delay the occurrence of refractory ascites is a very important clinical issue. Therapies of refractory ascites Several strategies parzcentesis treat refractory ascites have been developed and tested with commplicaciones studies, randomized trials, and meta-analysis. LVP with albumin and transjugular intrahepatic portosystemic shunt TIPS are the most used strategies, and they will be specifically discussed.
Thus, caution should be adopted in patients who has reached these alterations. Copmlicaciones transgiugular-intrahepatic portosystemic shunt TIPS is a porto-systemic shunt obtained by an intravascular insertion of a stent bridging a portal branch with an hepatic vein.
By contrast, the frequency is higher for long-term risks such as hepatic encephalopathy, the occlusion of the stent, hemolytic anemia, cardiac dysfunction. Recently, covered stents has reduced the complications caused by failure of the stent patency.
Accordingly, a strict selection of candidates could obviate most of such complications. Notwithstanding, all these advantages should be weighted with the consistent higher risk of encephalopathy. Moreover, a post hoc analysis from Campbell 27 demonstrated that patients with refractory ascites randomized to TIPS or LVP had similar alterations of their quality of life, due to the greater development of hepatic encephalopathy in patients receiving TIPS and to the more frequent taps in patients treated with LVP.
Thus, the comparison between TIPS and LVP should be re-evaluated in the light of the stable complicaviones effects achieved by the covered stents.
Conflict of interests The authors declare no conflict of interest. Natural history and prognostic indicators of survival in cirrhosis: J Hepatol, 44pp. N Engl J Med,pp. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis.
Hepatology, 38pp. Bacterial infection in patients with advanced cirrhosis: Dig Liver Dis, 33pp.
Ascites in Hepatic Cirrhosis
Bacterial infections, sepsis, and multi-organ failure in cirrhosis. Semin Liver Dis, 28pp. Liver Int, 30pp. EASL clinical practice guidelines on thev management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome I in cirrhosis. J Hepatol, 53pp. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis.
Gastroenterology,pp. J Hepatol, 56pp. Am J Gastroenterol,pp. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology, 37pp. LaVeen continuous peritoneal-jugular shunt. Improvement of renal function in ascitic patients. JAMA,pp.
Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. Treatment of patients with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: