Ascites represents the most frequent complication of hepatic cirrhosis and
its appearance involves a negative prognosis. From a physiopathological point
of view, ascitic decompensation is the result of post-sinusoidal portal hypertension
and of the concomitant sodium renal retention. The medical treatment of ascites,
whose guidelines are produced by international consensus conferences, is based
on a reduced dietetic sodium intake and on the administration of diuretic
drugs. In view of the crucial role played by secondary hyperaldosteronism
in the onset of sodium renal retention, anti-aldosteronic diuretics represent
the drug of first choice, which should be associated with a loop diuretic
in the event of therapeutic failure. Therapeutic paracentesis, associated
with adequate plasma expansion, represents the approach to be chosen in the
event of massive or refractory ascites. This latter form, which is described
as an abdominal effusion that cannot be mobilized through a hyposodic diet
and the administration of spironolactone (400 mg/day) and furosemide (160/day),
occurs in slightly less than 20% of cases, especially in advanced cirrhotic
patients, and involves a serious prognosis. When the therapeutic paracenteses
required to control the reforming of ascites become particularly frequent,
alternative therapeutic approaches are indicated. Peritoneovenous shunts have
now become obsolete, whereas there is great interest for the transjugular
intrahepatic shunt (TIPS). Thanks to this technique, very encouraging results
have been achieved, but additional experience is still required, especially
in order to adequately select patients. Indeed, the TIPS is certainly effective
in controlling ascites, but it may worsen the residual hepatic function and
negatively influence the survival of certain patients affected by advanced
cirrhosis. The survival rate ensured by liver transplantation exceeds today
that of ascites with cirrhosis, especially if refractory. For this reason,
the development of an ascitic decompensation is a factor that ought to involve
the patient’s candidacy for transplantation, provided no contraindications
exist. The waiting time length, which differs from one Centre to the other,
represents a crucial element for deciding at which time this option should
be selected.
