Dead Man Walking: The Horror of Alcoholic Ascites

Alcoholism, sometimes denoted as Alcohol Use Disorder, has been a curse on humanity since they created refined alcohol.  Alcoholism provides a binary choice: abstinence or a progressive march to death due to systemic poisoning and the resultant destruction of critical organs.   Alcoholism has ineffective treatments, and the syndrome affects as much as 11.2 % of the adult American populace. 
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Likely, alcoholism is a complex mix of genetic factors and trauma.  While alcoholics and other addicts do severe damage to families and friends, they are still human beings and deserve treatment and respect as such.  

Normal Abdomen and Bloated Ascites Abdomen

The first step significant clinical consequence of alcoholism is cirrhosis. Cirrhosis is permanent scarring and damage to the liver, trading healthy tissue with scar tissue that prevents the liver from acting conventionally. The scar tissue can also partially block blood flow through the liver, and cirrhosis worsens, causing a condition known as portal hypertension.

Cirrhosis and portal hypertension are the commanding origins of ascites, accounting for about 80% of cases in Western countries.    That's when long-term alcohol abuse causes scarring of the liver tissues, which obstructs blood flow through the portal vein running through the liver.
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Clinical outlooks for liver cirrhosis have two phases: the symptomless stage, also named 'compensated cirrhosis,' and the phase of problems due to the advance of portal hypertension and liver dysfunction, also called 'decompensated cirrhosis,' where patients may develop ascites, the most frequent complication from liver cirrhosis.

Scarred Cirrhotic Liver

When fluid from these enlarged veins leaks into the abdomen, it builds up inside the peritoneal cavity, causing ascites. Ascites cause uncomfortable swelling in the abdomen and can affect appetite and digestion. In severe cases, it extends into the chest cavity and interferes with breathing. It's also a risk factor for infection in the peritoneal cavity, resulting in peritonitis.
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The march towards ascites is straightforward.  A heavy drinker damages their liver through years of heavy drinking; scar tissue stiffens the organ, and then they develop uncomplicated ascites. Hepatic decompensation, defined by ascites, hepatic encephalopathy, and portal hypertensive gastrointestinal bleeding, is an essential landmark in the natural history of cirrhosis. 

Man with Ascites

Even patients who are ambulatory and have cirrhotic ascites have a 3-year mortality rate of 50%. Patients with refractory ascites have a 1-year survival of less than 50%. 
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A silent path characterizes the natural history of cirrhosis until decompensation when the progressive deterioration of liver function causes a rapid decline in life expectancy. The disease's early stage is 'compensated cirrhosis.' At the same time, the late one, defined by the appearance of ascites, bleeding, brain disease, or jaundice, is 'decompensated cirrhosis.' Due to the strikingly different survival rates, compensated and decompensated cirrhosis are considered two distinct clinical entities.

Man with Ascites Profile View

Management of Uncomplicated Ascites:

• Reducing dietary salt intake and increasing renal sodium excretion are the initial cornerstones of ascites management.
• Diuretics are used as symptomatic treatments, not affecting the general course of the disease, since they act downstream in the pathophysiological cascade.
• Large volume paracentesis (LVP) is the treatment of choice due to its effectiveness and low rate of complications.  LVP requires inserting a needle in the patient's abdomen and drawing excess fluid from the cavity, alleviating the pressure on the patient's body.
• All patients with cirrhosis should be evaluated for liver transplantation, as that is the only cure.

Refractory ascites (RA) is the term for a patient's progressive lack of response to diuretic therapy (diuretic-resistant RA).
Management of Refractory Ascites

• RA dramatically worsens patients' prognosis, reducing the median survival to about six months.
• Periodic execution of LVPs is agreed to be the treatment of choice for patients with RA.
• In a meta-analysis of randomized controlled trials, human albumin solution (HAS) was shown to reduce the risk of mortality compared to other strategies in patients undergoing LVP.
• Diuretic therapy is either reduced or withdrawn due to the high risk of diuretic-related complications.
• Trans-jugular intra-hepatic portosystemic shunts (TIPS) can address portal hypertension, a critical factor in decompensated cirrhosis. TIPS consists of creating an artificial shunt between the portal and hepatic vein, thus decreasing portal hypertension.
• A dreaded complication of advanced liver disease is hepatorenal syndrome (HRS). In its most lethal form (type I), there is a relentless deterioration of renal function, reflected in soaring creatinine and BUN, resulting in death. This syndrome always occurs with ascites.
• Liver replacement is the best treatment option because it is associated with 2-year survival rates of almost 85%.

Abdominal wall and inguinal hernias are common in patients with cirrhosis and ascites because of the incredible abdominal pressure from fluid buildup. Umbilical hernias grow in about 20% of patients with cirrhosis.  Increased abdominal pressure from ascites, weakened abdominal muscles, and poor nutrition can rapidly enlarge hernias.

Ascites Bloated Abdomen

​Bacterial infections are present in approximately one-third of patients with cirrhosis who are hospitalized, a much higher prevalence than in those without cirrhosis.   A familiar yet unique type of infection in this setting is infections that occur without an obvious source of infection. Bacterial translocation, the migration of bacteria from the gut to the bloodstream and other extraintestinal sites, and decreased host defenses have been implicated in the pathogenesis of these spontaneous infections.  Other common infections in cirrhosis are urinary tract infections, pneumonia, and soft tissue.

Liver replacement is the best treatment for cirrhosis and cirrhotic ascites. Experts have different opinions about the referral timing, but physicians should contemplate it when a cirrhotic patient first presents with difficulty from cirrhosis, such as ascites. Because refractory ascites portends imminent death, time is critical.
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Alcoholism offers a mortal choice to those afflicted – quit drinking or die a miserable death at a young age.  As it results from a complicated array of factors and is incredibly difficult to treat, it seems sad for humanity.  Despite that, formal education about the consequences and other public health measures are essential to implement and would result in significant positive outcomes.