
a reduction in diuretic treatment. A combination of
frusemide and spironolactone diuretic therapy is
often used. The latter is potassium-sparing and may
result in hyperkalemia after prolonged use. Other
interventions include paracentesis (removal of large
volumes of ascitic fluid via a cannula).
0026 If a low-sodium/no-added-salt diet and diuretic
therapy do not work, the ascites is classified as refrac-
tory/resistant, and transplantation or surgical proced-
ures will be required to alleviate the symptoms.
Sodium Restriction
0027 These patients will be extremely catabolic, and dis-
play anorexia. Meeting their nutritional requirements
is paramount and also extremely difficult without
supplementary feeding. Reducing salt intake will
automatically result in reduced palatability and pos-
sibly further reduce the patient’s intake. During hos-
pitalization, it is much easier to impose a sodium
restriction on patients whilst ensuring that energy
and protein requirements are met. Once discharged,
this level of restriction is very difficult to maintain,
and a ‘realistic’ diet of no added salt must be
prescribed. An example of a no-added-salt diet is
shown in Table 6. This will depend on the patient’s
socio-economic background, motivation, mental
acuity and prognosis. Cutting down salt intake will
also help with adherence to the fluid restriction,
which is often imposed at 750–1500 ml day
1
.
0028Oral supplements and nasogastric feeds should be
chosen carefully. Feeds low in sodium and volume
(i.e., 2 kcal ml
1
) will be ideal.
0029Confusion often arises over serum sodium levels.
Irrespective of the serum levels (patients are normally
hyponatremic), no-added-salt diets should always be
prescribed/encouraged for all patients with ascites.
Varices
0030These are veins that have become grossly enlarged as a
consequence of portal hypertension. They are caused
by the development of venous back flow as a result of
portal vein obstruction by the cirrhotic liver. They are
more often seen in the lower 5 cm of the esophagus
and fundus of the stomach. The most significant com-
plication of varices is hemorrhage, which is fatal for
50% of patients.
tbl0006 Table 6 Low-sodium alternatives
Low-sodiumenergy and protein-dense foods High-sodium foods ^ to be avoided
Meat, fish, poultry
Fresh or frozen meat, fish, poultry (roast, fry, cook with
unsalted butter or oil), tinned fish in oil or water (not brine)
Sausages, tinned meat, tinned fish in brine, corned beef, bacon,
ham, gammon, burgers, pies, ready meals, smoked/pickled
meat/fish, fish in batter, pa
ˆ
te
´
, sandwich spreads, salami, etc.
Dairy products
Full-cream milk, yogurt, fromage frais, all creams, cream
cheese, mozzarella, cottage cheese, ricotta cheese, eggs
Lassi, most cheeses not mentioned in the ‘USE’ list, all processed
cheeses, e.g., cheese spreads/slices
Fats and oils
All oils, unsalted butter Dressings, bottled sauces, mayonnaise
Cereals and breads
Shredded Wheat, Raisin Splitz, Sugar Puffs, puffed wheat,
porridge, unsalted muesli, all flours, bread, rolls, pasta
Most other breakfast cereals, rich breads, e.g., brioche, focaccia,
ciabatta, croissant, pot noodles
Fruit and vegetables
Fresh, frozen, tinned or dried fruit, fresh or frozen vegetables,
tinned tomatoes, tomato pure
´
e, tinned vegetables in water
only, all fruit juices
Dried, pickled, and most tinned vegetables, olives, gherkins, etc.
Savory snacks
Unsalted nuts, peanuts and raisins, Smiths ‘Shake þ Salt’
crisps (throw away the salt sachet), all butter popcorn
Salted nuts, crisps, Twiglets, salted popcorn and other salted
snacks
Biscuits
Most biscuits – especially Jaffa Cakes, wafers, Kit-kat, Malted
milk, Bourbon creams, Nice, plain Hobnobs, Matzo crackers
Digestives, shortbread cheese biscuits, Ryvita
Sweet snacks/condiments
All milky puddings, custard, cakes, gateaux, chocolate,
especially Smarties, Walnut whips, plain chocolate, Fry’s
chocolate cream, After Eights, fruit sweets – boiled sweets,
jelly babies, pastilles, Opal Fruits, marmalade, jam, honey,
chocolate spread
Fudge, toffees, Marmite, peanut butter, Vegemite
Drinks and miscellaneous
Whole milk, hot chocolate, milk shake, yogurt shakes,
Lucozade, cordials
Soup, stock cubes, Bovril, Marmite, Build Up Soup
LIVER/Nutritional Management of Liver and Biliary Disorders 3607