TIPS and refractory ascites. Lessons from the recent history of ascites therapy.

EFRACTORY ascites, a term introduced during the R 1950’s to define the ascites not responding to sodium restriction and diuretics, was an extremely frequent condition prior to the 1960’s, when the medical treatment of ascites consisted of the administration of mercurial or thiazide diuretics. These agents have a poor natriuretic effect in patients with marked hyperaldosteronism, who represent approximately 50% of the patients with cirrhosis admitted to hospital with tense ascites. These patients were then treated by large-volume paracentesis. Loop diuretics and spironolactone were introduced in clinical practice in 1960, and this represented a major step forward. Spironolactone was found to be effective in most cases not responding to thiazides (1). On the other hand, the association of spironolactone and furosemide or ethacrynic acid potentiated the natriuretic effect of each drug while reducing their side effects on potassium metabolism (2). Using these modern diuretics the prevalence of refractory ascites was decreased to less than 10%. Refractory ascites, however, continued to be a major problem in clinical practice since at that time large-volume paracentesis was suggested as a precipitating factor of hepatorenal syndrome (3) and, therefore, it was no longer used as a specific treatment of patients with cirrhosis and ascites. Sporadic reports on the potential usefulness of side-to-side portacaval shunt in the treatment of refractory ascites have appeared since 1955 (4). However, it has never gained general acceptance due to the significant early postoperative mortality and high incidence of chronic incapacitating encephalopathy associated with this procedure (5). Another treatment of refractory ascites with a transient popu-