Elsevier

Journal of Hepatology

Volume 53, Issue 3, September 2010, Pages 397-417
Journal of Hepatology

Clinical Practice Guidelines
EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis

https://doi.org/10.1016/j.jhep.2010.05.004Get rights and content

Section snippets

1.1. Evaluation of patients with ascites

Approximately 75% of patients presenting with ascites in Western Europe or the USA have cirrhosis as the underlying cause. For the remaining patients, ascites is caused by malignancy, heart failure, tuberculosis, pancreatic disease, or other miscellaneous causes.

1.2. Diagnosis of ascites

The initial evaluation of a patient with ascites should include history, physical examination, abdominal ultrasound, and laboratory assessment of liver function, renal function, serum and urine electrolytes, as well as an analysis of

2.1. Evaluation of patients with refractory ascites

According to the criteria of the International Ascites Club, refractory ascites is defined as “ascites that cannot be mobilized or the early recurrence of which (i.e., after LVP) cannot be satisfactorily prevented by medical therapy” [11], [56]. The diagnostic criteria of refractory ascites are shown in Table 3.

Once ascites becomes refractory to medical treatment, the median survival of patients is approximately 6 months [7], [56], [57], [58], [59]. As a consequence, patients with refractory

3. Spontaneous bacterial peritonitis

SBP is a very common bacterial infection in patients with cirrhosis and ascites [10], [105], [106], [107]. When first described, its mortality exceeded 90% but it has been reduced to approximately 20% with early diagnosis and treatment [6], [108].

4. Hyponatremia

Hyponatremia is common in patients with decompensated cirrhosis and is related to impaired solute-free water excretion secondary to non-osmotic hypersecretion of vasopressin (the antidiuretic hormone), which results in a disproportionate retention of water relative to sodium retention [163], [164], [165], [166]. Hyponatremia in cirrhosis is arbitrarily defined when serum sodium concentration decreases below 130 mmol/L [163], but reductions below 135 mmol/L should also be considered as

5.1. Definition and diagnosis of hepatorenal syndrome

Hepatorenal syndrome (HRS) is defined as the occurrence of renal failure in a patient with advanced liver disease in the absence of an identifiable cause of renal failure [56]. Thus, the diagnosis is essentially one of exclusion of other causes of renal failure. In 1994 the International Ascites Club defined the major criteria for the diagnosis of HRS and designated HRS into type 1 and type 2 HRS [56]. These were modified in 2007 [192]. The new diagnostic criteria are shown in Table 8. Various

Acknowledgement

The authors would like to thank Nicki van Berckel for her excellent work in the preparation of the manuscript.

Disclosure: Kevin Moore recieved grant/research support from Olsuka. He served as a consultant for the company and was paid for his consulting services.

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    Correspondence: 7 rue des Battoirs, CH-1205 Geneva, Switzerland. Tel.: +41 22 807 0360; fax: +41 22 328 07 24.

    Contributors: Chairman: Pere Ginès; Clinical Practice Guidelines Members: Paolo Angeli, Kurt Lenz, Søren Møller, Kevin Moore, Richard Moreau; Journal of Hepatology Representative: Carlo Merkel; EASL Governing Board Representatives: Helmer Ring-Larsen and Mauro Bernardi; Reviewers: Guadalupe Garcia-Tsao, Peter Hayes.

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