How ti prevent further decompensation in patients with ascites?

Patients with decompensated cirrhosis should be considered for liver transplantation.

Patients with ascites who are not on traditional NSBBs (i.e., propranolol or nadolol) or carvedilol should undergo screening endoscopy.

TIPS should be considered in patients with recurrent ascites (requirement of ≥3 large-volume paracenteses within 1 year) irrespective of the presence or absence of varices or history of variceal haemorrhage.

In patients with ascites and low-risk varices (small [<5 mm], no red signs, not Child-Pugh C), traditional NSBBs or carvedilol may be used to prevent first variceal haemorrhage.

In patients with ascites and high-risk varices (large varices [≥5 mm]), or red spot signs, or Child-Pugh C), prevention of first variceal haemorrhage is indicated, with traditional NSBBs or carvedilol being preferred over EVL.

In patients with ascites, traditional NSBBs or carvedilol should be dose-reduced or discontinued in case of persistently low blood pressure (systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg) and/or HRS-AKI.(B.1) Once blood pressure returns to baseline and/or HRS-AKI resolves, NSBBs can be re-initiated or re-titrated.(B.1) If a patient remains intolerant to NSBBs, EVL is then recommended to prevent variceal haemorrhage.

References:

Corrigendum to ‘Baveno VII – Renewing consensus in portal hypertension’ [J Hepatol (2022) 959-974] Journal of Hepatology, Vol. 77, Issue 2