Moore Kevin P, Wong Florence, Gines Pere, Bernardi Mauro, Ochs Andreas, Salerno Francesco, Angeli Paolo, Porayko Michael, Moreau Richard, Garcia-Tsao Guadelupe, Jimenez Wladimiro, Planas Ramon, Arroyo Vicente
Centre for Hepatology, Royal Free and University College Medical School, UCL, London, United Kingdom.
Hepatology. 2003 Jul;38(1):258-66. doi: 10.1053/jhep.2003.50315.
Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis.
腹水是肝硬化的常见并发症，预示着肝硬化进程中肝脏失代偿的新阶段。腹水的出现预示着预后显著恶化。诊断腹水的非肝硬化病因（如恶性肿瘤、结核病和胰源性腹水）很重要，因为这些病因在肝病患者中出现的频率增加。代表从北美到欧洲临床实践范围的国际腹水俱乐部已通过共识制定了从早期腹水阶段到难治性腹水阶段肝硬化腹水管理指南。轻度至中度腹水首先应通过适度限制盐摄入以及使用螺内酯或等效药物进行利尿治疗。应在维持钠限制的同时逐步添加利尿剂。大量腹水应采用治疗性腹腔穿刺术，随后进行胶体扩容和利尿治疗。难治性腹水通过反复大量腹腔穿刺术或插入经颈静脉肝内门体分流术（TIPS）进行管理。成功放置TIPS可改善患者的肾功能、钠排泄和总体健康状况，但未证实对生存有益。照顾这些患者的临床医生应了解每种治疗方式的潜在并发症，并准备好在出现并发症或禁忌症时停用利尿剂或不进行TIPS放置。所有腹水患者均应考虑肝移植，最好在肾功能不全发生之前进行，以防止其预后进一步恶化。
