欧洲肝脏学会2010年指南。

ClinicalPracticeGuidelines

EASLclinicalpracticeguidelinesonthemanagementof

ascites,spontaneousbacterialperitonitis,andhepatorenal

syndromeincirrhosis

EuropeanAssociationfortheStudyoftheLiver1

Ascitesisthemostcommoncomplicationofcirrhosis,and 60%Fortheremainingpatients,ascitesiscausedbymalignancy,heartofpatientswithcompensatedcirrhosisdevelopasciteswithinfailure,tuberculosis,pancreaticdisease,orothermiscellaneous10yearsduringthecourseoftheirdisease[1].Ascitesonlyoccurscauses.

whenportalhypertensionhasdeveloped[2]andisprimarily

relatedtoaninabilitytoexcreteanadequateamountofsodium

intourine,leadingtoapositivesodiumbalance.Alargebodyof1.2.Diagnosisofascites

evidencesuggeststhatrenalsodiumretentioninpatientswith

cirrhosisissecondarytoarterialsplanchnicvasodilation.ThisTheinitialevaluationofapatientwithascitesshouldcausesadecreaseineffectivearterialbloodvolumewithactiva-includehistory,physicalexamination,abdominalultrasound,tionofarterialandcardiopulmonaryvolumereceptors,andandlaboratoryassessmentofliverfunction,renalfunction,homeostaticactivationofvasoconstrictorandsodium-retainingserumandurineelectrolytes,aswellasananalysisofthesystems(i.e.,thesympatheticnervoussystemandtherenin–ascitic uid.

angiotensin–aldosteronesystem).RenalsodiumretentionleadsTheInternationalAscitesClubproposedtolinkthechoiceoftoexpansionoftheextracellular uidvolumeandformationoftreatmentofuncomplicatedascitestoaclassi cationofascitesascitesandedema[3–5].Thedevelopmentofascitesisassociatedonthebasisofaquantitativecriterion(Table2).Theauthorsofwithapoorprognosisandimpairedqualityoflifeinpatientswiththecurrentguidelinesagreewiththisproposal.cirrhosis[6,7].Thus,patientswithascitesshouldgenerallybecon-Adiagnosticparacentesiswithanappropriateascitic uidsideredforreferralforlivertransplantation.Thereisaclearratio-analysisisessentialinallpatientsinvestigatedforascitespriornaleforthemanagementofascitesinpatientswithcirrhosis,asatoanytherapytoexcludecausesofascitesotherthancirrhosissuccessfultreatmentmayimprovetheoutcomeandsymptoms.andruleoutspontaneousbacterialperitonitis(SBP)incirrhosis.ApanelofexpertswasselectedbytheEASLGoverningBoardWhenthediagnosisofcirrhosisisnotclinicallyevident,ascitesandmetseveraltimestodiscussandwritetheseguidelinesduetoportalhypertensioncanbereadilydifferentiatedfromduring2008–2009.Theseguidelineswerewrittenaccordingtoascitesduetoothercausesbytheserum–ascitesalbumingradi-publishedstudiesretrievedfromPubmed.Theevidenceandent(SAAG).IftheSAAGisgreaterthanorequalto1.1g/dl(orrecommendationsmadeintheseguidelineshavebeengraded11g/L),ascitesisascribedtoportalhypertensionwithanapprox-accordingtotheGRADEsystem(GradingofRecommendationsimate97%accuracy[8,9].Totalascitic uidproteinconcentrationAssessmentDevelopmentandEvaluation).Thestrengthofevi-shouldbemeasuredtoassesstheriskofSBPsincepatientswithdencehasbeenclassi edintothreelevels:A,high;B,moderate;proteinconcentrationlowerthan15g/LhaveanincreasedriskofandC,low-qualityevidence,whilethatoftherecommendationSBP[10].

intotwo:strongandweak(Table1).WherenoclearevidenceAneutrophilcountshouldbeobtainedtoruleouttheexis-existed,therecommendationswerebasedontheconsensustenceofSBP[10].Ascitic uidinoculation(10ml)inbloodcul-adviceofexpertopinion(s)intheliteratureandthatoftheturebottlesshouldbeperformedatthebedsideinallpatients.writingcommittee.Othertests,suchasamylase,cytology,PCRandcultureformyco-

bacteriashouldbedoneonlywhenthediagnosisisunclearorif

1.Uncomplicatedascitesthereisaclinicalsuspicionofpancreaticdisease,malignancy,or

tuberculosis[8–11].

1.1.EvaluationofpatientswithascitesRecommendationsAdiagnosticparacentesisshouldbeper-

formedinallpatientswithnewonsetgrade2or3ascites,and

Approximately75%ofpatientspresentingwithascitesinWes-inallpatientshospitalizedforworseningofascitesoranyternEuropeortheUSAhavecirrhosisastheunderlyingcause.complicationofcirrhosis(LevelA1).

Contributors:Chairman:PereGinès;ClinicalPracticeGuidelinesMembers:Paolo

Angeli,KurtLenz,SørenMøller,KevinMoore,RichardMoreau;Journalof

Received25May2010;accepted25May2010HepatologyRepresentative:CarloMerkel;EASLGoverningBoardRepresentatives:1Correspondence:7ruedesBattoirs,CH-1205Geneva,Switzerland.Tel.:+41HelmerRing-LarsenandMauroBernardi;Reviewers:GuadalupeGarcia-Tsao,228070360;fax:+412232807

24.Peter

Hayes.

JournalofHepatology2010vol.53j

397–417