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2017 ; 5
(2
): 104-112
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Ascites, refractory ascites and hyponatremia in cirrhosis
#MMPMID28533908
Fortune B
; Cardenas A
Gastroenterol Rep (Oxf)
2017[May]; 5
(2
): 104-112
PMID28533908
show ga
Ascites is the most common complication related to cirrhosis and is associated
with increased morbidity and mortality. Ascites is a consequence of the loss of
compensatory mechanisms to maintain the overall effective arterial blood volume
due to worsening splanchnic arterial vasodilation as a result of clinically
significant portal hypertension. In order to maintain effective arterial blood
volume, vasoconstrictor and antinatriuretic pathways are activated, which
increase overall sodium and fluid retention. As a result of progressive
splanchnic arterial vasodilation, intestinal capillary pressure increases and
results in the formation of protein-poor fluid within the abdominal cavity due to
increased capillary permeability from the hepatic sinusoidal hypertension. In
some patients, the fluid can translocate across diaphragmatic fenestrations into
the pleural space, leading to hepatic hydrothorax. In addition, infectious
complications such as spontaneous bacterial peritonitis can occur. Eventually, as
the liver disease progresses related to higher portal pressures, loss of a
compensatory cardiac output and further splanchnic vasodilation, kidney function
becomes compromised from worsening renal vasoconstriction as well as the
development of impaired solute-free water excretion and severe sodium retention.
These mechanisms then translate into significant clinical complications, such as
refractory ascites, hepatorenal syndrome and hyponatremia, and all are linked to
increased short-term mortality. Currently, liver transplantation is the only
curative option for this spectrum of clinical manifestations but ongoing research
has led to further insight on alternative approaches. This review will further
explore the current understanding on the pathophysiology and management of
ascites as well as expand on two advanced clinical consequences of advanced liver
disease, refractory ascites and hyponatremia.
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