Professor El-Omar has chosen Professor Guruprasad Aithal, Deputy Director and Theme Lead, NIHR Nottingham Biomedical Research Centre, Nottingham Digestive Diseases Centre, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK, to do the next #GUTBlog.

The #GUTBlog focusses on the latest BSG and BASL Guideline, “Guidelines on the management of ascites in cirrhosis” published online in Gut in October 2020, but in paper copy in January 2021. Professor Guruprasad Aithal is the lead author on this guideline, working together with a broad team of specialists to produce this paper.

Beethoven to Bedside

“In mid-January 1827, when Ludwig van Beethoven developed ascites, his secretary, Anton Schindler, arranged a ‘Council of Physicians’ which recommended frozen punch containing alcohol! Eventually, ‘to preclude the danger of sudden bursting, abdominal puncture was advocated’. With almost immediate relief, Beethoven cried out that the procedure made him think of Moses, who ‘struck the rock with his staff and made the water gush forth’. Beethoven received repeated paracentesis in the remaining months of life and 2 days following his last, he expired aged 56 years. On autopsy “the abdominal cavity was filled with four quarts of a reddish, cloudy fluid, liver shrunken to half its normal volume, beset with bean-sized knots and the spleen was double its proper size.” ‘Ludwig was partial to alcoholic beverage too’; he died of spontaneous bacterial peritonitis (SBP) secondary to alcohol-related cirrhosis.

Historically, appeal to authority appears to be a common method of drawing inference. Many guidelines have been based upon expert opinion or consensus. Only a small subset of what is done in medicine has been tested robustly in well-designed studies. Even then, studies are stronger if subjects are homogenous, rather than representative. It still remains clinician’s responsibility to apply the best evidence based test or intervention into the context of an individual patient. One such example is that the diagnostic yield from tapping ascites varies with the prevalence of different underlying aetiology and the latter in a contemporary cohort of patients presenting to National Health Services is substantially different to that previously described. Similarly, changing landscape of bacterial resistance mandates that local policies (rather than sweeping national/ international recommendations) to be developed regarding choice of antibiotics for empirical treatment of SBP. Overall, primary aim of the ‘Guideline on the management of ascites in cirrhosis’ is to be the key source of evidence accompanied by the essence of the context in which it is generated. Recent guideline is enriched by several systematic reviews performed by experienced clinicians paired with specialty trainees in relevant topics including the diagnostic tests, treatment of salt and water retention, large volume paracentesis, transjugular intrahepatic portosystemic stent shunts (TIPSS), use of albumin and SBP. Narrative summaries in 12 supplementary tables provide a backdrop to the recommendations.

Over the years, experience and evidence has accumulated in relation to ascites drainage, bench marking for training to perform the procedure and performance standards of day case large volume paracentesis service have been proposed in the article. Infusion of human albumin solution post-therapeutic paracentesis is associated with 57 to 100 fewer patients per 1000 dying following the procedure. In addition, insertion of long-term abdominal drain may facilitate symptom guided drainage of fluid at home and reduce hospitalisation. In parallel, adoption of polytetrafluoroethylene-covered stents as standard of care and methodical patient selection have improved 1-year survival with TIPSS performed for ascites without any increased incidence of hepatic encephalopathy. It is now recognised that volume of procedures performed in an individual hospital improves outcome with lower in-patient mortality in centres with more than 20 TIPSS insertions per year.

Questions remain as to whether and when to perform TIPSS for hepatic hydrothorax and surgical repair for umbilical hernia complicating large ascites. While the concerns regarding non-selective beta-blocker therapy in refractory ascites have receded, the role of regular human albumin solution infusion to improve long-term morbidity and mortality continues to be debated. Guidelines include recommendations for research in specific areas of priority.

Goals of all treatments are to improve the way patients feel, function or survive. Rigorously developed evidence based guidelines can enhance quality of care and minimise potential harm. However, they are only one option for improving clinical services and may do little to other barriers that stand in the way of behaviour changes.”

Professor Guruprasad P. Aithal

Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham

NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK