Consensus report

consensus report

Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)   

9

1 3

Refractory ascites

1.  Refractory ascites is defined as ascites that cannot 

be mobilized by intensive diuretic therapy (< 0.8  kg 

weight loss within 4 days) or that is uncontrollable by 

total paracentesis, substitution of albumin, and ad-

equate diuretic therapy up to a maximum of 400 mg 

spironolactone and 160 mg furosemide per day (asci-

tes resistant to diuretic therapy).

2.   Early recurrence (within 4 weeks) of grade 2 or grade 3 

ascites after paracentesis is also defined as refractory 

ascites [

2

].

3.   Ascites is also defined as refractory, when the maximal 

dose of diuretics cannot be administered due to side 

effects such as electrolyte imbalance, renal failure, 

and encephalopathy (ascites intolerant to diuretics).

4.  For diagnosis of refractory ascites, analysis of 24  h 

urine specimens for protein levels, creatinine clear-

ance, and sodium excretion should be performed.

5.   A characteristic feature of refractory ascites is an im-

paired urinary sodium excretion (< 90  mmol/24  h) 

[

49

]. Diuretic treatment should be administered only 

when urinary sodium excretion under diuretic thera-

py is greater than 30 mmol/day [

2

].

6.   Due to the poor prognosis of patients with refractory 

ascites, liver transplantation should be considered. 

In patients awaiting liver transplantation or with con-

traindications to transplantation, therapy of ascites 

should consist of repeated total paracentesis with al-

bumin substitution, sodium restriction and diuretic 

therapy (II-2).

7.   In selected patients (see Chap. 14: “TIPS for therapy 

of portal hypertension”), TIPS is a good and effec-

tive therapeutic alternative to repeated paracente-

ses. Especially in patients with contraindications to 

liver transplantation or in patients with expected long 

waiting times for transplantation, TIPS implantation 

should be considered (II-1).

Spontaneous bacterial peritonitis (SBP)

Definition and management of SBP

1.   All patients presenting with ascites for the first time, 

with recurrence of ascites, and deterioration of ascites 

need investigation of ascites. Paracentesis should also 

be performed in patients suspected to have systemic 

infection (either clinically or by laboratory tests), 

worsening liver or renal function, and hepatic en-

cephalopathy [

50

] ascitic fluid culture should be per-

formed in blood culture bottles at bedside. Together 

with paracentesis, blood should be investigated for 

infection (blood culture). Even in the absence of signs 

of infection in the ascitic fluid, positive blood cultures 

hint at the responsible organism [

51

].

2.   In case of an ascitic fluid neutrophil count > 250/µL 

and/or a positive ascitic fluid culture, antibiotic thera-

py using a broad-spectrum antibiotic with good gram-

negative efficacy should be started immediately (e.g., 

3

rd

 generation cephalosporine, quinolone, aminope-

nicillin/penicillinase inhibitor) (I). The use of reagent 

strips cannot be recommended at present [

52

] (II-1).

3.   In case of an ascitic fluid neutrophil count < 250/µL 

and the presence of clinical signs of infection, broad-

spectrum antibiotic therapy should be started and 

continued until the microbiological results from the 

ascitic fluid are available (III). Other causes of abdom-

inal bacterial infections or peritoneal carcinosis have 

to be excluded in patients with high neutrophil count 

and multimicrobial cultures.

4.   Repeat paracentesis should be performed 48  h after 

initiation of the antibiotic therapy to demonstrate a 

drop of the ascites neutrophil count to 25 % of the ini-

tial value (III). A smaller drop is highly suggestive of 

failure of the antibiotic regimen [

50

].

5.   Patients with an ascitic fluid neutrophil count > 250/µL 

and clinical suspicion of SBP should implicitly receive 

albumin intravenously in addition to broad spectrum 

antibiotics to prevent hepatorenal syndrome (I): 1.5 g/

kg body weight within 6 hours of diagnosis plus 1 g/kg 

on day 3 [

52

].

Long-term prophylaxis of SBP

1.   In patients with severe liver disease and ascites, but 

without a previous episode of SPB, long-term prophy-

laxis using antibiotics can be indicated when the as-

citic total protein concentration is below 1.5 g/dL [

50

] 

(I). Given the inevitable risk of developing resistant 

organisms, the use of prophylactic antibiotics should 

be restricted to patients at high risk for SBP.

2.  All patients who experienced one episode of SPB 

should be treated continuously using oral quinolones 

(norfloxacin, ciprofloxacin) (I). The use of rifaximin in 

this indication should be explored.

3.   Due to the poor prognosis of patients who recovered 

from SBP, liver transplantation should be considered 

in these patients (II-2).

Transjugular intrahepatic portosystemic shunt 

(TIPS) for therapy of portal hypertension [

3

]

General suppositions for TIPS placement

1.   Radiologic examination for evaluation of the paten-

cy of anatomical structures (veins of the liver, portal 

vein) as the prerequisite for the technical success.

2.   Echocardiography to detect contraindications for TIPS 

(cardiac insufficiency, pulmonary hypertension).

3.  Sufficient liver function, i.e., Child-Pugh score ≤ 11 

and MELD ≤ 17.

4.  In patients with Child-Pugh score > 11 and MELD 

> 18, TIPS implantation should be considered very 

carefully.

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