Ascites - Causes, symptoms and treatment. MF.

Ascites( abdominal dropsy, abdominal edema) - a significant accumulation of free fluid, usually non-inflammatory nature( transudate) in the abdominal cavity.

Causes of ascites

Ascites can occur in various diseases and pathological conditions:

1. With portal hypertension( increased pressure in the portal vein system that collects blood from a significant number of abdominal cavities) of different origin with the development of blockage of outflow of blood through the portal vein at levelliver( cirrhosis of the liver), superhepatic( thrombosis of the hepatic veins) or subheading level( thrombosis of the portal vein, compression and germination of it with tumors of nearby organs).Due to a significant increase in hydrostatic pressure in the portal vein system, blood plasma from the veins of the stomach, intestine and spleen swims into the free abdominal cavity, accumulating there.
2. Decompensated chronic heart failure with the development of stagnation in a large circle of circulation and edematous syndrome.

3. Kidney disease, accompanied by the development of nephrotic syndrome( glomerulonephritis, kidney amyloidosis and others).
4. Alimentary dystrophy.
5. Development of an obstruction for lymphatic drainage through the lymphatic duct.
6. Infection of the peritoneum with malignant tumor cells( peritoneal carcinomatosis).
7. Peritoneal inflammation of the tuberculosis process( so-called ascites-peritonitis).

The listed reasons can be combined and aggravate each other. Thus, in cirrhosis of the liver, the development of ascites, in addition to intrahepatic portal hypertension, is facilitated by a decrease in the oncotic pressure of blood plasma due to a decrease in the amount of protein in it, especially its important variety - albumin, caused by a violation of its formation in the liver with cirrhosis;as well as the retention of water and sodium in the body, due to insufficient inactivation( elimination of biological activity) of aldosterone and antidiuretic hormone( hormones regulating water-salt metabolism in the body).

In children, ascites may be a manifestation of congenital, hereditary or acquired pathology:

1. With a general congenital edema caused by group( AV0) and Rh-incompatibility of fetal and maternal blood( hemolytic disease of newborns).Such children are not viable and die, usually in the first hours after birth.
2. With a common congenital edema caused by hidden fetal blood loss.
3. In case of lesion of biliary tract and liver in infants.
4. Consequence of chronic eating disorder in kwashiorkore - a form of severe dystrophy against the background of a lack of proteins in the diet.
5. Exudative enteropathy is a hereditary disease caused by the loss of blood plasma and plasma proteins through the gastrointestinal tract.
6. Congenital nephrotic syndrome.
In children of older age, the causes of ascites are largely the same as in adults.

Ascites

The main manifestations of ascites are caused by the dynamic accumulation of fluid in the abdominal cavity. The onset of this pathological condition is usually gradual, it develops within a few months, however, with portal vein thrombosis, it can occur quite swiftly.

Gradual development of ascites, as a rule, is accompanied by flatulence( bloating), the manifestations of which can initially prevail in the clinical picture. With an increase in the amount of the transudate in the abdominal cavity, the circumference of the patient's stomach gradually increases. In the vertical position, the stomach acquires a globular shape with a projecting forward or sagging lower half, and in the horizontal position takes a peculiar flattened form of the "frog stomach": flattened in the peripodal region and protruded in the lateral sections. With the accumulation of a significant amount of fluid, the abdominal wall is strained, and the skin is stretched, thinned and smoothened, the navel is bulging outward, white strips on the skin - striae( stretch marks) may appear.

In ascites caused by portal hypertension, in contrast to ascites in other diseases, there are no edema, hydropericardium( fluid accumulation in the pericardial sac) and hydrothorax( fluid accumulation in the pleural cavities).However, even with such ascites, if it reaches a significant value, a large volume of the transudate leads to compression of the inferior vena cava and obstructing the outflow of blood from the lower extremities, which can cause edema on the legs. Also, with ascites due to portal hypertension, the subcutaneous veins may expand on the lateral surface of the trunk and around the navel( the "jellyfish head").

The type of abdomen of a patient with ascites caused by cirrhosis of the liver. There is an increase in the size of the abdomen, bulging of the navel, the presence of enlarged subcutaneous veins in the anterior abdominal wall( "jellyfish head")

Ascites examination

The doctor determines the dullness of the percussion sound during the examination( percussion - tapping on individual parts of the body with subsequent analysis of the sound phenomena occurring atthis) over the accumulated fluid in the flattened or lateral part of the abdomen, and this dullness moves when the position of the body changes, since the fluid flows freely from one part of the abdomenth cavity in another. In addition, when applying light, abrupt strokes with the right hand along one side wall of the abdomen, the physician senses transfer waves( the phenomenon of fluctuations) with the left hand applied to the side wall of the abdomen from the opposite side.

From the instrumental methods of examination, the most informative are ultrasound and computed tomography of the abdominal organs, which not only allow to detect even small amounts of free fluid in the abdominal cavity and estimate its volume, but also, in most cases, to determine the cause of ascites( cirrhosis,portal vein tumor and others).

Free fluid in ascites( marked with an arrow), detected by ultrasound examination of the abdominal cavity

What tests should I take with ascites

1. General blood test: usually has no independent diagnostic significance in ascites, as changes in this pathology are generally not observed. In cases of far-reaching cirrhosis of the liver that caused ascites, anemia and an increase in ESR are possible.
2. General urine analysis: may reflect characteristic changes in ascites caused by cirrhosis of the liver: proteinuria( excretion of protein in the urine), presence in the urine of cylinders( cylindruria), erythrocytes( microhematuria);as well as in ascites caused by kidney disease due to a violation of their function: massive proteinuria, cylindruria, hematuria, increased relative density of urine.
3. Biochemical blood test: can reflect changes caused by impaired renal function( hypoproteinemia - decrease in plasma protein content, increase in nitrogenous slag content) or liver( increased direct and indirect bilirubin, hypoproteinemia, increased alanine aminotransferase, etc.).
4. The general analysis of the fluid obtained from abdominal puncture in ascites corresponds to the transudate: the liquid is clear, in some cases may contain a bloody impurity or have a chylosis( milky) character, has a neutral or slightly alkaline reaction, the protein content in it does not exceed 2,5%( 25 g / l), the relative density is not more than 1.015.
5. Rivolta( Rivolta) assay is a qualitative reaction to a protein used to distinguish between a transudate and an exudate. In a solution of acetic acid, the laboratory assistant adds 1-2 drops of the test fluid from the abdominal cavity. In an acid medium, the dissolved protein is denatured and precipitates. If the falling drop forms a haze in the form of a white cloud dropping to the bottom of a laboratory tube, the sample is positive, suggesting that the test fluid is an exudate with a protein content of more than 3%.A drop of the transudate does not cause turbidity.
6. Cytological examination of evacuated with abdominal puncture fluid allows excluding ascites of tumor origin( pleural carcinomatosis).To do this, the fluid obtained during puncture is centrifuged and cytological preparations( smears) are prepared from the sediment, which are then color-treated according to the Romanovsky-Giemsa method. Prepared in this way, the doctor-cytologist studies under a microscope. In ascites, tumor cells in the smear should not be, but cells of the mesothelium lining the inside of the abdominal cavity can be detected.
7. Bacteriological study of fluid from the abdominal cavity is performed to exclude tuberculous ascitic peritonitis. A sowing of the fluid obtained during abdominal puncture is performed on artificial nutrient media with subsequent evaluation of the results of germination of microorganisms.

Treatment of ascites

Treatment with ascites is reduced to therapeutic measures and surgical procedures.
Therapeutic measures are aimed at treating the underlying disease. In order to reduce the delay in the body of sodium chloride, a salt-free diet is prescribed, diuretics, drugs - aldosterone antagonists.

In the case of ascites in cirrhosis, the amount of liquid to be drunk to 1.5 liters per day and table salt( diet No. 7) is limited, the amount of protein in the daily diet should be at least 70-80 g.

If a patient has heart failure, excludepsychoemotional stress conditions, prescribe diet No. 10 or No. 10a with restriction of water intake and table salt, prescribe drugs that increase the reduced contractility of the myocardium( cardiac glycosides, β-adrenoreceptor stimulants, ingphosphodiesterase), drugs that help to remove excess fluid from the body - diuretics( inhibitors of carbonic anhydrase, "loop", thiazide and thiazide, potassium-sparing diuretics) and drugs that reduce the load on the left ventricle of the heart( peripheral venous, arterial and mixed vasodilatingagents, ACE inhibitors).

With kidney diseases , accompanied by the development of nephrotic syndrome( glomerulonephritis, amyloidosis of the kidneys) and leading to the appearance of ascites, a bed regimen is prescribed that promotes increased urine production, diet number 7 with a significant restriction of salt intake( until completely excluded from dietat the expressed edematic syndrome) and the control of quantity of a drunk liquid which should not exceed more than on 200-300 ml volume of the urine allocated for a day. Correction of violations of protein metabolism is due to the intake of optimal amounts of protein from the food, as well as the use of drugs that help to reduce protein losses in the urine( ACE inhibitors);if necessary, pour a 20% solution of albumin( 100-150 ml once every 2-3 days with a course of up to 5-6 infusions);appoint diuretics( thiazide, "loop", potassium-sparing diuretics).

In newborns with a general congenital edema caused by hidden blood loss, symptomatic treatment is carried out, which consists in transfusion of plasma and blood. When exkudative enteropathy in children, transfusion of blood plasma is used in the calculation of 5-10 ml per 1 kg of the child's weight, glucocorticosteroids, aldactone( veroshpiron) are administered.

In the presence of a significant amount of ascitic fluid, is used to drain the abdominal cavity with the gradual removal of the transudate from it. Before this, the patient must necessarily empty the bladder. Manipulation is performed in the patient's sitting position under local anesthesia, usually at a point in the middle of the distance between the umbilicus and the pubis where a 0.5% novocaine solution of 20 ml volume is injected layer by layer into the soft tissues. After that, the scalpel surgeon cuts through the skin and injects into the abdominal cavity the trocar - a special tool consisting of an acute stiletto inserted into the hollow shell( tube).After extracting the stylet through the channel of the sleeve( tube) of the trocar, the surgeon inserts the drainage into the abdominal cavity and removes the liner. To avoid a sharp drop in intra-abdominal pressure during the release of ascitic fluid, which can cause collapse( a sharp drop in blood pressure), fluid evacuation is slow and intermittent. For a more complete evacuation of the liquid as it expires, the nurse pulls the stomach of the patient with a towel that girdles the belly above and below the drainage site. The procedure for weakened patients can be stretched for 8-20 hours, after which drainage from the abdominal cavity is removed.

In the presence of ascites due to portal hypertension, sometimes resort to various surgical interventions. At the so-called operation, the Kalba surgically excise the peritoneum and muscles in the lumbar region, after which the fluid begins to be absorbed by the subcutaneous tissue( this operation is effective in 30% of cases), but the formed "window" functions only for 1-6 months. The most widely used is the formation of vascular anastomoses between the branches of the lower hollow and portal veins, which leads to a decrease in pressure in the portal vein system and prevents the development of ascites.

Complications of ascites

If there is a large amount of fluid in the abdominal cavity, respiratory failure and congestion of the right heart can result from the compression of the upright diaphragm of the lungs and large vessels. In case of infection, it is possible to develop peritonitis( inflammation of the peritoneum), which is an extremely serious disease requiring urgent surgical intervention.

Prophylaxis of ascites

Prevention is the timely and adequate treatment of diseases that, if decompensated, can lead to its development.

Forecast

The prognosis for ascites is largely determined by the underlying disease. It is considered serious if, contrary to treatment, the volume of fluid in the abdominal cavity continues to increase rapidly. The prognostic value of ascitesum itself is that its growth aggravates the severity of the underlying disease.

Doctor surgeon Kletkin ME