Interventional procedure overview of tunnelled peritoneal drainage catheter insertion of refractory ascites in cirrhosis

Existing assessments of this procedure

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver (Aithal 2020) guideline on the management of ascites in cirrhosis recommends that:

5. Large volume paracentesis (LVP)

5.1. Patients should give informed consent for a therapeutic or diagnostic paracentesis. (Quality of evidence: low; Recommendation: strong)

5.2. Ultrasound guidance should be considered when available during LVP to reduce the risk of adverse events (Quality of evidence: low; Recommendation: weak)

5.3. Routine measurement of the prothrombin time and platelet count before therapeutic or diagnostic paracentesis and infusion of blood products are not recommended. (Quality of evidence: moderate ; Recommendation: strong)

6. Use of human albumin solution (HAS)

6.1. Albumin (as 20% or 25% solution) should be infused after paracentesis of >5 litre is completed at a dose of 8 g albumin/litre of ascites removed. (Quality of evidence: high; Recommendation: strong)

6.2. Albumin (as 20% or 25% solution) can be considered after paracentesis of within 6 hours of diagnosis, followed by 1 g/kg on day 3, is recommended. (Quality of evidence: low; Recommendation: weak)

7. Transjugular intrahepatic portosystemic shunt (TIPSS)

7.1. TIPSS should be considered in patients with refractory ascites. (Quality of evidence: high; Recommendation: strong)

7.2. Caution is required if considering TIPSS in patients with age >70 years, serum bilirubin >50 micromol/litre, platelet count < 75×109 /litre, model for end-stage liver disease (MELD) score ≥18, current hepatic encephalopathy, active infection or hepatorenal syndrome. (Quality of evidence: moderate; Recommendation: strong).

12. Palliative care

12.1. Patients with refractory ascites who are not having evaluation for liver transplant should be offered a palliative care referral. Besides repeated LVP, alternative palliative interventions for refractory ascites should also be considered. (Quality of evidence: weak; Recommendation: strong)

Research recommendation

13.8. Effectiveness and safety of long-term abdominal drains should be assessed in RCTs for the palliative care of patients with cirrhosis and refractory ascites (Aithal GP 2020).

The American Association for the Study of Liver Diseases (AASLD, Biggins 2021) guidance on the diagnosis, evaluation, and management of ascites and hepato-renal syndrome (HRS) in patients with chronic liver disease recommends the following treatment options.

Medical treatment options for refractory ascites

Guidance Statements

•Continued dietary sodium restriction (<2 g/day) is required in patients with RA to reduce the rate of ascites accumulation.

•Fluid restriction is ineffective for the management of RA, but restricting fluid intake to less than 1,000 ml/day is recommended for treatment of hyponatremia (e.g., <125 mEq/litre).

•In the management of RA, there are insufficient data to recommend the long- term use of albumin infusions outside the setting of large- volume paracenteses.

LVP

Guidance Statements

•LVP is the first- line treatment for RA.

•Albumin infusion at the time of LVP of >5 litre is recommended to mitigate the risk of PPCD. The risk of PPCD may increase with >8 litre of fluid evacuated in one single session.

•The recommended dose of albumin replacement, based on expert opinion, is 6-8 g for every litre of ascites removed.

TIPS and Liver Transplantation

Guidance Statements

•Careful patient selection is the key to the success of TIPS in the management of RA.

•A small- diameter coated stent of less than 10 mm is preferred to reduce the likelihood of post-TIPS complications, including hepatic encephalopathy.

•If ascites recurs after initial clearance, a TIPS venogram should be considered, and TIPS revision should be performed if stenosis is identified. In those patients, periodic Doppler ultrasound surveillance should be considered.

•Liver Transplantation should be considered in patients with RA

The European Association for the Study of the Liver clinical practice guidelines (Angeli 2018) for the management of patients with decompensated cirrhosis states that:

Repeated LVP plus albumin (8 g/ of ascites removed) are recommended as first line treatment for refractory ascites (I;1).

Diuretics should be discontinued in patients with refractory ascites who do not excrete >30 mmol/day of sodium under diuretic treatment (III;1).

Patients with refractory or recurrent ascites (I;1), or those for whom paracentesis is ineffective (for example, because of the presence of loculated ascites) should be evaluated for TIPS insertion (III;1).

TIPS insertion is recommended in patients with recurrent ascites (I;1) as it improves survival (I;1) and in patients with refractory ascites as it improve the control of ascites (I;1).