Management of “Intractable” Ascites in Decompensated Cirrhosis

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TRADITIONAL management of a patient with cirrhosis of the liver and associated ascites comprises a high-protein diet with supplemental vitamins and repeated paracenteses when the extent of ascites interferes with respiration, appetite, or comfort. Paracentesis has been given undue credit as a therapeutic measure, inasmuch as improvement in the patient usually has resulted from improved nutrition and hepatocellular function. Repeated paracenteses leach out the patient’s plasma protein by plasmapheresis and actually are harmful. A most pitiful patient is the one with so-called intractable ascites, whose course involves progressive muscular wasting and cachexia as the ascites reaccumulates more rapidly after each paracentesis until the onset of jaundice, hepatic coma, hemorrhage from esophageal varices, and finally death.

We believe that too much reliance has been placed on repeated paracenteses as the only treatment for the cirrhotic patient with ascites, and that too little emphasis has been placed on the strict medical treatment. It is not sufficient simply to hand the patient a diet sheet outlining a high-protein and high-caloric intake. The responsible physician must see to it that the patient follows the prescribed diet. It is too easy to think: “This patient has intractable ascites and all we can do is to tap him repeatedly.” Strict attention to minute details of medical management of the patient, although tedious, will usually cause a favorable response to treatment.

We shall discuss in this report the treatment of intractable ascites caused by decompensated cirrhosis, and the favorable response to it of five patients referred to . . .



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