TREATMENT OF DIURETIC-REFRACTORY HEPATOGE NOUS ASCITES

A minority of patients with liver cirrhosis and ascites (10-15%) appea rs refractory to conventional diuretic therapy. The diagnosis of refra ctory ascites presupposes a careful evaluation of underlying as well a s concomitant organ diseases in order to recognize pseudo-refractory f orms of ascites (e.g. renal failure due to an overdose of diuretics or spontaneous bacterial peritonitis). In the context of basal therapy o f ascites, we would like to focus on the following points: The complia nce of patients with hepatogenous ascites is very important in regard to dietetic rules (e.g. slow sodium diet, fluid restriction and daily control of weight). Albumin substitution should be done in patients wi th a reduced serum protein concentration. Additionally, we recommend m uscle training. Diuretic therapy and paracenteses with concomitant alb umin substitution should be used moderately and not in an aggressive w ay in the treatment of ascites. Due to our experience the use of furos emide can be given up. In the rare cases of diuretic-refractory ascite s shunt creation (e.g. TIPS) and liver transplantation are the most ap propriate and effective forms of therapy. The effectiveness of TIPS in the treatment of refractory ascites is examplified by a case report. For better evaluation of TIPS further controlled studies should be per formed comparing TIPS with peritoneovenous shunts and paracentesis. In the context of the different forms of therapy it should be realized t hat hepatogenous ascites does not represent a disease of its own, but is only a symptom of an underlying liver disease. which should primari ly determine the therapeutical procedure.