Chapters authored
Modern Tools for Diagnosis in Tuberculous Ascites
Tuberculosis (TB) is a highly contagious bacterial infection caused by Mycobacterium tuberculosis (MTB), affecting about 1/3rd of the world population and being responsible for lot of deaths worldwide, despite the progress achieved in the diagnosis and treatment fields. TB can affect the peritoneum, the TB ascites being a concern for physicians, especially when dealing with immunocompromised patients. The clinical presentation of TB ascites is challenging, due to nonspecific symptoms that make confusion with other diseases and the late results of cultures from ascites. The late diagnosis leads to a delayed treatment and high mortality. This manuscript describes recent tools used for early diagnosis in TB ascites. Molecular methods based on mycobacterial nucleic acid amplification tests (NAATs), polymerase chain reaction (PCR) detecting minimal amounts of bacterial DNA, or interferongamma release assays (IGRA) and biochemical methods such as the serum-ascites albumin gradient (SAAG) <1.1 g/dL, ratio between lactic dehydrogenase (LDH) in ascites fluid/serum total protein (TP) ratio of 0.5 and fluid ascites/serum LDH ratio of 0.6, and adenosine deaminase activity (ADA) > 40 UI/ml were recently considered more accurate diagnostic procedures. These methods allow a rapid and accurate differential diagnosis of ascites fluid, making possible the early treatment with appropriate drugs.
Part of the book: Ascites
Management of Ascites Associated with Severe Hyponatremia
Advanced liver cirrhosis requiring hospitalization is frequently associated with electrolytic disturbances, the most common finding being serum hyponatremia. The goal of treatment in patients with decompensated liver cirrhosis complicated with severe hyponatremia is to normalize the increased amount of water in the body and to improve the sodium concentration. Fluid restriction is recommended at 1.5 L/day to prevent sodium depletion in the serum, but the lack of efficacy is probably due to a poor patient compliance. Discontinuation or adjustments of diuretic dosages are sometimes required. Albumin associated with vasoconstrictors as midodrine can increase the effective arterial blood volume and seems to improve the serum sodium concentration. A promising therapeutic option targeting the pathophysiological mechanism of hyponatremia consists of improving solute-free water excretion, which is markedly impaired in these patients. The use of agents such as k opioid agonists has been attempted, but has been dropped due to the severe side effects. Recently, a new therapeutic class called vaptans has taken an important place in the treatment of hypervolemic hyponatremia. The main side effects during the administration of these drugs in patients with liver cirrhosis are reversible after discontinuing therapy. Therefore, it is recommended to use vaptans for short periods of time.
Part of the book: Management of Chronic Liver Diseases