Treatment of Refractory Ascites by Retransfusion and Peritoneovenous Shunting

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Abstract
Ascites retransfusion or peritoneovenous shunting is used for the relief of ascites refractory to standard medical treatment. In one third of patients, intravascular coagulopathy has been observed after shunt insertion; bleeding led to a postoperative lethality of about 20%. The pathophysiology of this complication has remained unknown so far. Since conventional parameters failed to predict the incidence of coagulation abnormalities, we studied the role of plasminogen in ascitic fluid. Forty-four patients underwent ascites retransfusion, either extracorporeal (n = 16) or by peritoneovenous shunting (n = 28). All patients with plasminogen levels below 0.7 CTA U/ml showed signs of fibrinolysis during retransfusion, 5 of them bled. The patients with a plasminogen concentration above 0.7 CTA U/ml had no coagulation abnormalities. An increase in plasminogen concentration was induced by injections of dexamethasone intraperitoneally. If the concentration reached 0.7 CTA U/ml prior to retransfusion, no coagulation abnormalities occurred. We conclude that the plasminogen concentration in ascitic fluid is a reliable prognostic parameter for the occurrence of coagulopathy after ascites retransfusion.

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