Monitoring of blood pressure at home provides useful information for the provider to factor into the decision when to taper or stop antihypertensives. Propranolol has been shown to shorten survival in patients with refractory ascites in a prospective study.8 This could be the

result of its negative effect on blood pressure and the increase in the rate of paracentesis-induced circulatory dysfunction that is noted in patients who are taking propranolol in the setting of refractory ascites.9 Blood pressure and renal function should be monitored closely in patients who have refractory ascites. www.selleckchem.com/products/PLX-4032.html The risks versus benefits of beta blockers must be weighed carefully in each patient. Consideration should be given to discontinuing beta blockers or not initiating beta blockers in those patients with refractory ascites and those who develop worsening hypotension or worsening azotemia. In the current version of this guideline, there are also new sections on umbilical hernias, hepatic hydrothorax, and cellulitis. Chest-tube insertion in hepatic hydrothorax is advised against, based on

older and newer studies.10, 11 Percutaneous endoscopic gastrostomy is advised against in patients with cirrhosis and ascites.12 Many patients with cirrhosis and ascites in the current era have multiple insults to the liver, including alcohol. Cessation of alcohol intake can dramatically MCE improve their degree of liver failure, despite the selleckchem continued presence of hepatitis C and/or NASH. Refractory ascites can revert to diuretic sensitive and can even disappear such that diuretics can be tapered and even stopped over time. Baclofen has been shown, in a randomized trial that included only patients with alcoholic liver disease, to reduce alcohol craving and alcohol consumption;

it can be given at a dose of 5 mg orally three times daily (TID) for 3 days and then 10 mg TID.13 The dose can be tailored upward, with the patient carrying “a pill in the pocket” and taking an extra pill as needed to reduce alcohol craving.14 An outpatient appointment within 7 days of discharge from the hospital has been shown to correlate with lower readmissions rates of patients with heart failure.15 Rapid return to clinic may also reduce the readmission rates of patients with cirrhosis and ascites by frequent adjustment of doses of diuretics and prevention of dehydration versus tense ascites. The utility of monitoring urine sodium/potassium ratios is reiterated based on new data.16 Vaptans are discussed in this revision. Earlier studies of vaptans had focused on heart failure and included a relatively small number of patients with cirrhosis. These drugs are very expensive and may cause thirst.