Correspondence

Care of Patients with Ascites

N Engl J Med 1994; 330:1827-1828June 23, 1994

Article

To the Editor:

In his review of the care of patients with ascites (Feb. 3 issue),1 Runyon downplays surgical treatments, such as peritoneovenous shunting. One option not mentioned is formal surgical portosystemic shunting, usually with an end-to-side portacaval shunt or a short, small-diameter H-graft reconstruction (a short interposition graft between the portal vein and vena cava). Both operations will reduce ascites and are analogous to the procedure used for transjugular intrahepatic portosystemic shunts. For patients with truly refractory ascites, in whom a peritoneal shunt is impossible, the risk of encephalopathy from a portosystemic shunt may be outweighed by the advantage of fluid control.

Jeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 01199

1 References

1. 1

   Runyon BA. Care of patients with ascites. N Engl J Med 1994;330:337-342
   Full Text | Web of Science | Medline

To the Editor:

Although he stresses the usefulness of the serum-ascites albumin gradient, Runyon claims that measurement of fibronectin or cholesterol in ascitic fluid is not useful for the differential diagnosis of ascites. We have a different view. A test for fibronectin1 or cholesterol2 in ascitic fluid can accurately discriminate between malignant and nonmalignant ascites and is superior to protein measurement for this purpose. The serum-ascites albumin gradient may be inferior to ascitic-fluid cholesterol measurement in the differential diagnosis of ascites3-5. For these reasons, we advocate the measurement of ascitic-fluid cholesterol.

A.L. Gerbes, M.D.
University of Munich, 81377 Munich, Germany

J. Scholmerich, M.D.
University of Regensburg, 93053 Regensburg, Germany

5 References

1. 1

   Scholmerich J, Volk BA, Kottgen E, Ehlers S, Gerok W. Fibronectin concentration in ascites differentiates between malignant and nonmalignant ascites. Gastroenterology 1984;87:1160-1164
   Web of Science | Medline

2. 2

   Jungst D, Gerbes AL, Martin R, Paumgartner G. Value of ascitic lipids in the differentiation between cirrhotic and malignant ascites. Hepatology 1986;6:239-243
   CrossRef | Web of Science | Medline

3. 3

   Gerbes AL, Jungst D, Xie YN, Permanetter W, Paumgartner G. Ascitic fluid analysis for the differentiation of malignancy-related and nonmalignant ascites: proposal of a diagnostic sequence. Cancer 1991;68:1808-1814
   CrossRef | Web of Science | Medline

4. 4

   Prieto M, Gomez-Lechon MJ, Hoyos M, Castell JV, Carrasco D, Berenguer J. Diagnosis of malignant ascites: comparison of ascitic fibronectin, cholesterol, and serum-ascites albumin difference. Dig Dis Sci 1988;33:833-838
   CrossRef | Web of Science | Medline

5. 5

   Misra SP, Dwivedi M, Misra V, Gupta R, Agarwal SK. Diagnostic paracentesis. Gastroenterology 1990;99:902-903
   Web of Science | Medline

To the Editor:

Runyon argues that therapeutic paracentesis decreases protein and complement in both ascites and serum and may predispose patients to bacterial infections, whereas diuretic treatment of ascites conserves and concentrates complement in serum and ascites. No increased incidence of infections has been reported, however, in patients treated with therapeutic paracentesis, perhaps because a low complement concentration is only one of many factors that may increase the risk of infection in such patients. Other factors include impaired activity of the reticuloendothelial system, defective neutrophil chemotaxis, impaired activity of bactericidal IgM antibodies, decreased neutrophil intracellular destruction of phagocytized bacteria, and decreased serum opsonic activity1. In contrast, therapeutic paracentesis has been reported to be associated with fewer complications than diuretic treatment of ascites,2 as Runyon points out. We think therapeutic paracentesis should be an initial treatment for the majority of patients with cirrhosis and tense or non-tense ascites.

Eduardo Montero, M.D., Ph.D.
Joaquin Miguel, M.D.
Joaquin Lopez-Alvarez, M.D., Ph.D.
Hospital Universitario Principe de Asturias, 28805 Madrid, Spain

2 References

1. 1

   Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastroenterol Clin North Am 1992;21:257-275
   Web of Science | Medline

2. 2

   Arroyo V, Gines P. Therapeutic paracentesis in cirrhotic patients with ascites. In: Rodes J, Arroyo V, eds. Therapy in liver diseases. Barcelona, Spain: Doyma, 1992:156-65.
   

Author/Editor Response

Dr. Runyon replies:

To the Editor: Kaufman suggests an important role for surgical treatment of patients with ascites and favors end-toside portacaval or short H-graft shunts. The side-to-side portacaval shunt reduces intrahepatic sinusoidal pressure more than other shunts and appears to be the most effective shunt for treatment of ascites. However, the hepatic encephalopathy that frequently complicates portacaval shunting dampened enthusiasm for the use of this procedure in the treatment of ascites many years ago. A recent study of 57 patients concludes that “the high rate of postoperative encephalopathy is a strong argument against” the use of portosystemic shunts in the management of intractable ascites1. In my experience, most patients with ascites prefer not to take the risk of being confused postoperatively and decide against portosystemic shunting when presented with the realistic options.

Gerbes and Scholmerich prefer to use ascitic-fluid concentrations of fibronectin or cholesterol to classify fluid specimens as benign or malignant. Unfortunately, these “humoral tests of malignancy” are nonspecific and are frequently inaccurate in patients who have ascites that is not caused by cancer (e.g., ascites caused by tuberculous peritonitis, cardiac ascites, or pancreatic ascites)2. Cancer can cause ascites by multiple mechanisms, including peritoneal carcinomatosis, portal hypertension due to massive liver replacement with tumor, lymph-node obstruction and lymphatic leak due to lymphoma, and hepatic-vein obstruction by tumor. The results of ascitic-fluid analysis in patients with these conditions vary tremendously2. The utility of a single test is very low. A battery of simple tests, including the serum-ascites albumin gradient, is required to discriminate among the various causes of ascites2.

Montero et al. favor therapeutic paracentesis in the initial treatment of people with ascites. This treatment is acceptable but leads to opsonin depletion (as compared with diuretic treatment alone) even when diuretics are used after the initial paracentesis3.

Bruce A. Runyon, M.D.
University of Louisville, Louisville, KY 40292

3 References

1. 1

   Franco D, Vons C, Traynor O, de Smadja C. Should portosystemic shunt be reconsidered in the treatment of intractable ascites in cirrhosis? Arch Surg 1988;123:987-991
   Web of Science | Medline

2. 2

   Runyon BA. Malignancy-related ascites and ascitic fluid “humoral tests of malignancy.” J Clin Gastroenterol 1994;18:94-98
   CrossRef | Web of Science | Medline

3. 3

   Ljubicic N, Bilic A, Kopjar B. Diuretics vs. paracentesis followed by diuretics in cirrhosis: effect on ascites opsonic activity and immunoglobulin and complement concentrations. Hepatology 1994;19:346-353
   CrossRef | Web of Science | Medline