Cirrhosis and its complications are among the top 10 causes of death in the United States.1,2 One of the most common complications of cirrhosis is ascites, an abnormal accumulation of fluid in the peritoneal cavity.3 Although ascites can be of nonhepatic origin, in approximately 85% of cases, the cause is cirrhosis.2,4
Developing in some 60% of cirrhosis patients within 10 years,3 ascites indicates disease progression from compensated to decompensated cirrhosis.5 Mortality from ascites is approximately 15% in the first year and 44% by the fifth year, so referral for liver transplant evaluation is often indicated.2
Frequently, however, patients do not meet the criteria for transplantation because of comorbidities such as morbid obesity, severe cardiac or pulmonary disease, severe malignancy, chemical dependency, or lack of caregiver support.6 Primary care clinicians need to know about the management of ascites in chronic liver disease in order to meet the significant ongoing health care needs of these patients.
This article reviews the diagnosis and treatment of cirrhosis-related ascites and discusses one particularly life-threatening infection—spontaneous bacterial peritonitis (SBP)—to which these patients are susceptible.
CASE A 52-year-old African-American man presented to the emergency department (ED) with complaints of severe diffuse abdominal pain, worsening over the past few days, as well as nausea and vomiting. History was significant for hepatitis C–related cirrhosis, unresponsive to antiviral treatment, and liver disease complications that included hepatic encephalopathy; portal hypertension; ascites requiring large-volume paracentesis every one to two weeks (most recently, six days earlier); esophageal varices (status postbanding by esophagogastroduodenoscopy); portal hypertensive gastropathy; and gastric varices.
Due to decompensated cirrhosis, the patient had previously undergone extensive screening, radiologic imaging, and laboratory testing, and was found by a multidisciplinary selection committee to be an acceptable liver transplant candidate. He was actively listed for transplantation.
Other significant history included hypertension; sleep apnea; gastroesophageal reflux; osteopenia; zinc, vitamin A, and vitamin D deficiencies; thrombocytopenia; and anemia of chronic disease (liver disease–related). Surgical history was negative. The patient reported no known drug allergies and was taking spironolactone (50 mg/d) and furosemide (20 mg/d).
Physical exam was notable for a low-grade fever of 99.1ºF; blood pressure, 132/81 mm Hg; heart rate, 84 beats/min; icteric sclerae; and moderate distress related to the patient’s abdominal pain, which worsened with deep palpation. The abdomen was distended, with ascites present as indicated by a positive fluid wave test. Bowel sounds were hypoactive. The patient was alert and oriented without asterixis; mental state was within normal limits.
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