TREATMENT OF ASCITES - OLD AND NEW REMEDIES

Ascites is a common complication of chronic liver disease. Treatment o f the underlying liver disease with modalities such as abstinence from alcohol in Laennec's cirrhosis, phlebotomy in hemochromatosis, copper removal in Wilson's disease, and steroids in autoimmune liver disease , can improve survival in many patients. In addition, therapy of ascit es alleviates the symptoms and improves the quality of life of the pat ients, and probably decreases the incidence of life-threatening condit ions including spontaneous bacterial peritonitis and hepatorenal syndr ome. The mean survival rate at 2 years is approximately 50%. Precipita ting factors such as gastrointestinal bleeding, nonsteroidal anti-infl ammatory drugs and infections, should be identified, since most of the m can be corrected. Most cirrhotics with ascites can be managed with a 'step-by-step' approach, including dietary salt restrictions, aldoste rone antagonists, and loop diuretics. When tense or refractory ascites is present, large-volume paracentesis is safe and effective. Peritone ovenous shunting (i.e. Denver, LeVeen) is less frequently used because of perioperative morbidity and mortality, and thrombotic complication s with occlusion of the stent. Reinfusion of concentrated ascites is o f potential benefit and has been used in Europe. Transjugular intrahep atic portosystemic shunt (TIPS) is an alternative procedure performed by interventional radiologists that allows decompression of portal hyp ertension. In many cases, ascites is improved after TIPS, but long-ter m randomized trials for tense or refractory ascites comparing TIPS wit h standard therapy are not conclusive. Liver transplantation is the ul timate step for the treatment of ascites, providing the cure for the u nderlying liver disease as well. Transplantation is indicated when qua lity of life of the patient is impaired due to recurrent episodes of a scites, or in the presence of spontaneous bacterial peritonitis and he patorenal syndrome.