21 Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can induce
arterial hypotension and renal failure and should
also be avoided.
22 Nonselective beta-blockers are
a standard therapy for portal hypertension and
varices; however, they may negatively impact outcomes in patients with refractory ascites.
pressure and renal function should be closely
monitored in patients with refractory ascites; those
with deterioration may benefit from stopping these
Despite sodium restriction and diuretic titration
up to maximum recommended doses, recurrent
ascites is noted, requiring LVP of 8 to 10 L every
2 weeks. Dietary and medication compliance is
confirmed, and the urinary sodium excretion is low.
The patient presents to clinic to discuss alternative
therapies for refractory ascites.
Refractory ascites refers to ascites that cannot be
controlled by medical therapy either due to lack of
response or to diuretic-induced complications.
complication occurs in 10% of patients with ascites.
Treatment involves either serial LVPs or placement
of a transjugular intrahepatic portosystemic shunt
(TIPS). As noted above, albumin infusions should be
provided at the time of LVP to prevent paracentesis-induced circulatory dysfunction. The use of albumin in
this setting is also associated with reduced mortality.
TIPS is a side-to-side portacaval shunt that reduces portal pressure and improves the control of
ascites (Figure;2). It is placed by an interventional
radiologist using an endovascular approach. In patients with refractory ascites, TIPS induces natriuresis and reduction in the renin-angiotensin axis with
consequent improvement in ascites.25 Multiple controlled trials and meta-analyses have demonstrated
the efficacy of TIPS in controlling ascites. One of the
more recent of these meta-analyses demonstrated
improved survival with TIPS as well.26 Patients should
be advised that adequate natriuresis and mobilization of ascites might take several weeks following
TIPS placement.25 Patients should also be advised
of the risks and complications associated with TIPS.
Up to 30% of patients can develop hepatic encephalopathy following TIPS, with some developing refractory hepatic encephalopathy.27 Shunt stenosis and
thrombosis can also occur, although the risk of these
complications may be reduced with newer polytetra-fluoroethylene-covered stents.28
Patient selection is vital to achieving good outcomes. The Model for End-Stage Liver Disease
(MELD) was developed to predict 3-month mortality
following TIPS.29 Patients with a MELD score greater
than 15 to 18 have a high risk of complication and
death; TIPS should not be placed in these patients in
most circumstances.30 Several contraindications and
complications of TIPS are shown in Table 3.
Figure;2. Transjugular intrahepatic portosystemic shunt (TIPS)
placement diverting portal blood flow to the hepatic vein, thus
reducing portal pressure and improving ascites. (Reproduced
with permission from Sicklick JK, D'Angelica M, Fong Y. The
liver. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox
KL, eds. Sabiston textbook of surgery: the biological basis of
modern surgical practice. 19th ed. Philadelphia, PA: Elsevier
Saunders; 2012. Copyright © 2012, Elsevier.)