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Ascites – what is it?
Ascites is a secondary condition in which there is an accumulation of transudate or exudate in the abdominal cavity. Symptoms of pathology are manifested by an increase in the size of the abdomen, pain, shortness of breath, a feeling of heaviness and other signs.
In medicine, ascites is also called abdominal dropsy, which can accompany many diseases from the field of gynecology, gastroenterology, urology, cardiology, lymphology, oncology, etc. Ascites is not an independent disease, but acts as a symptom of one or another severe disorder in the body. Ascites of the abdominal cavity does not occur with mild pathologies, it always accompanies diseases that threaten human life.
Ascites statistics indicate that more than 70% of adults develop it as a result of liver disease. Tumors of the internal organs lead to the development of ascites in 10% of cases, another 5% are due to heart failure and other diseases. While in children, the development of ascites most often signals kidney disease.
It has been established that the maximum amount of fluid accumulating in the abdominal cavity with ascites in a patient can reach 25 liters.
Causes of ascites
The causes of abdominal ascites are varied and are always associated with some serious disorder in the human body. The abdominal cavity is a closed space in which excess fluid should not form. This place is intended for the internal organs – there is the stomach, liver, gallbladder, part of the intestine, spleen, pancreas.
The peritoneum is lined with two layers: the outer, which is attached to the wall of the abdomen, and the inner, which is adjacent to the organs and surrounds them. Normally, between these sheets there is always a small amount of fluid, which is the result of the work of blood and lymphatic vessels located in the peritoneal cavity. But this fluid does not accumulate, since almost immediately after the release, it is absorbed by the lymphatic capillaries. The remaining small part is necessary so that the intestinal loops and internal organs can move freely in the abdominal cavity and do not stick together.
When there is a violation of the barrier, excretory and resorptive function, the exudate ceases to be absorbed normally and accumulates in the abdomen, as a result of which ascites develops.
The causes of ascites are as follows:
Diseases of the liver. First of all, it is cirrhosis, as well as organ cancer and Budd-Chiari syndrome. Cirrhosis can develop against the background of hepatitis, steatosis, taking toxic drugs, alcoholism and other factors, but is always accompanied by the death of hepatocytes. As a result, normal liver cells are replaced by scar tissue, the organ increases in size, compresses the portal vein, and therefore ascites develops. A decrease in oncotic pressure also contributes to the release of excess fluid, because the liver itself is no longer able to synthesize plasma proteins and albumins. The pathological process is aggravated by a number of reflex reactions triggered by the body in response to liver failure;
Heart diseases. Ascites can develop due to heart failure, or due to constrictive pericarditis. Heart failure can be the result of almost all cardiac diseases. The mechanism of development of ascites in this case will be due to the fact that the hypertrophied cardiac muscle is not able to pump the necessary volumes of blood, which begins to accumulate in the blood vessels, including in the system of the inferior vena cava. As a result of high pressure, fluid will exit the vascular bed, forming ascites. The mechanism of development of ascites in pericarditis is approximately the same, but in this case, the outer shell of the heart becomes inflamed, which leads to the impossibility of its normal filling with blood. In the future, this affects the work of the venous system;
Kidney disease. Ascites is caused by chronic renal failure, which occurs as a result of a wide variety of diseases (pyelonephritis, glomerulonephritis, urolithiasis, etc.). Kidney diseases lead to the fact that blood pressure rises, sodium, along with the fluid, is retained in the body, as a result, ascites is formed. A decrease in plasma oncotic pressure, leading to ascites, can also occur against the background of nephrotic syndrome;
Damage to the lymphatic vessels. This happens due to trauma, due to the presence in the body of a tumor that gives metastases, due to infection with filariae (worms that lay eggs in large lymphatic vessels);
Various lesions of the peritoneum capable of provoking ascites, including diffuse, tuberculous and fungal peritonitis, peritoneal carcinosis, cancer of the colon, stomach, breast, ovaries, endometrium. This also includes pseudomyxoma and peritoneal mesothelioma;
Polyserosite is a disease in which ascites appears in combination with other symptoms, including pleurisy and pericarditis;
Systemic diseases can lead to accumulation of fluid in the peritoneum. These are rheumatism, rheumatoid arthritis, lupus erythematosus, etc.;
Ascites in newborns also occurs and is most often the result of hemolytic disease of the fetus. It, in turn, develops during an intrauterine immunological conflict, when the blood of the fetus and mother do not combine for a number of antigens;
Protein deficiency – one of the factors predisposing to the formation of ascites;
Diseases of the digestive system can cause excessive accumulation of fluid in the abdominal cavity. It can be pancreatitis, chronic diarrhea, Crohn’s disease. This also includes any processes that occur in the peritoneum and prevent lymphatic outflow;
Myxedema can lead to ascites. This disease is accompanied by swelling of soft tissues and mucous membranes, manifests itself in violation of the synthesis of thyroxine and triiodothyronine (thyroid hormones);
Serious nutritional deficiencies can cause abdominal ascites. Fasting and strict diets are especially dangerous in this regard. They lead to the fact that protein reserves in the body run out, the concentration of protein in the blood decreases, which leads to a pronounced decrease in oncotic pressure. As a result, the liquid part of the blood leaves the vascular bed and ascites is formed;
At an early age, ascites accompanies exudative enteropathy, malnutrition, and congenital nephrotic syndrome.
So, ascites can be based on a variety of inflammatory, hydrostatic, metabolic, hemodynamic and other disorders. They entail a number of pathological reactions of the body, as a result of which the interstitial fluid sweats through the veins and accumulates in the peritoneum.
Symptoms of ascites
The first symptom of ascites is an unprecedented increase in the abdomen, or rather, its swelling. The main reason for this is that a huge amount of liquid accumulates there, and it practically does not come out. A person usually finds ascites in himself when he cannot fit into his usual clothes, which until recently fit him in size.
If you have abdominal ascites, then there are probably at least two serious functional disorders in the body that need to be cured. Most often, this is a malfunction of the intestines, indigestion or liver pathology.
The rate of increase in symptoms is directly related to what exactly caused the ascites. The process can develop quickly, or it can take several months.
Symptoms of abdominal ascites are the following clinical signs:
Feeling of fullness in the abdominal cavity;
The occurrence of pain in the abdomen and pelvis (abdominal pain);
Bloating, symptoms of flatulence;
Belching and heartburn;
problems with digestion and urination;
Bouts of nausea;
Heaviness in the abdomen;
Enlargement of the abdomen. If the patient is in a horizontal position, then the abdomen bulges to the sides and resembles the appearance of a frog’s abdomen. When a person is standing, the stomach hangs down;
protrusion of the navel;
Abdominal fluctuation symptom or fluctuation. Always occurs when the abdominal cavity is filled with fluid;
The more fluid accumulates in the abdominal cavity, the stronger the shortness of breath becomes, the swelling of the lower extremities increases, the movements become slower. It is especially difficult for the patient to lean forward;
Due to the increase in intra-abdominal pressure, protrusion of the femoral or umbilical hernia is possible. Against the same background, hemorrhoids and varicocele can develop. Prolapse of the rectum is not ruled out.
The symptoms of ascites will differ somewhat depending on the etiological factor that provoked it:
Symptoms of ascites in tuberculous peritonitis. In this case, ascites is a consequence of a tuberculous lesion of the reproductive system, or intestines. The patient begins to rapidly lose weight, his body temperature rises, symptoms of intoxication of the body increase. The lymph nodes that run along the mesentery of the intestine are enlarged. In addition to lymphocytes and erythrocytes, mycobacterium tuberculosis will be isolated in the sediment of the exudate taken by puncture;
Symptoms of ascites in peritoneal carcinosis. If ascites is formed due to the presence of a tumor in the peritoneum, then the symptoms of the disease will primarily depend on which organ it has affected. However, always with ascites of oncological etiology, there is an increase in lymph nodes that can be palpated through the abdominal wall. Abnormal cells will be present in the effusion sediment;
Symptoms of ascites on the background of heart failure. The patient has a bluish discoloration of the skin. The lower extremities, especially the feet and lower legs, will swell very much. In this case, the liver increases in size, there are pains localized in the right hypochondrium. It is not excluded the accumulation of transudate in the pleural cavities;
Symptoms of ascites on the background of portal vein thrombosis. The patient will complain of severe pain, the liver increases in size, but not much. There is a high risk of developing massive bleeding from hemorrhoids, or from the veins of the esophagus, which have undergone varicose expansion. In addition to the enlargement of the liver, there is an increase in the size of the spleen.
Other symptoms of ascites:
If the cause of the pathology is portal hypertension, then the patient loses a lot of weight, feels sick and vomits. The skin turns yellow, a venous pattern appears on the abdomen like a “jellyfish head”;
Protein deficiency, as the cause of ascites, is indicated by severe edema of the extremities, accumulation of fluid in the pleural cavity;
With chylous ascites (at the terminal stage of liver cirrhosis), the fluid arrives very quickly, which affects the size of the abdomen;
Skin symptoms come to the fore with ascites, which develops against the background of rheumatic pathologies.
stages of ascites
There are three stages of ascites, which are determined by the amount of fluid in the peritoneal cavity:
The first stage is transient ascites. In this case, the volume of liquid does not exceed 400 ml. It is almost impossible to notice the symptoms of ascites on your own. Excess fluid can be seen during instrumental examinations (during MRI or ultrasound). The work of the abdominal organs due to the accumulation of such volumes of fluid is not disturbed. If a person notices any pathological symptoms in himself, then they will be associated with the underlying disease that provokes ascites.
The second stage is moderate ascites. The volume of fluid simultaneously located in the abdominal cavity can reach 4 liters. In this case, the patient already notices alarming symptoms, the stomach increases and begins to hang down while standing. Increased shortness of breath, especially in the supine position. The doctor is able to determine ascites based on the examination of the patient and palpation of his abdominal cavity.
The third stage is tense ascites. Liquid volumes will exceed 10 liters. At the same time, pressure in the abdominal cavity increases greatly, which leads to problems with the functioning of internal organs. The person’s condition is deteriorating and requires immediate medical attention.
Refractory ascites is isolated separately. In this case, the pathology most often does not respond to treatment, and the fluid, despite the ongoing therapy, continues to arrive in the abdominal cavity. The prognosis for the development of the disease is unfavorable for the life of the patient.
Treatment
Ascites treatment methods will be effective only if they are implemented in a timely manner. To begin with, the doctor must assess the stage of the pathology and find out what caused its development.
Medical treatment of ascites
The main drugs that help remove excess fluid from the body are diuretics. Thanks to their intake, it is possible to achieve the transition of excess fluid from the abdominal cavity into the bloodstream, which helps to reduce the symptoms of ascites. To begin with, patients are prescribed the smallest dose of diuretics to minimize the risk of side effects.
An important principle of treatment with diuretics is a slow increase in diuresis, which will not lead to significant losses of potassium and other important metabolites. At the same time, doctors monitor the patient’s diuresis daily and, if treatment is ineffective, increase the dose of drugs or replace them with stronger drugs.
In addition to diuretics, patients are prescribed drugs aimed at strengthening the walls of blood vessels (vitamin C, vitamin P), as well as drugs that prevent fluid from leaving the vascular bed.
Antibacterial drugs are prescribed if the disease that caused ascites is bacterial in nature.
Diet
The nutrition of the patient should be balanced and high-calorie, which will ensure the body’s needs for all the trace elements it needs. It is important to limit salt intake, and in its pure form it is forbidden to include it in the menu at all.
The amount of fluid consumed should also be adjusted downwards. Patients are not recommended to drink more than 1 liter of liquid per day, excluding soups.
It is important that the patient’s daily diet is enriched with protein food, but its amount should not be excessive. Fat intake should be reduced, especially in patients with ascites caused by pancreatitis.
Surgical intervention
Laparocentesis for abdominal ascites is performed if the patient remains resistant to medical correction. For the outflow of fluid, it is possible to install a peritoneovenous shunt with partial deperitonization of the walls of the abdominal cavity.
Operations aimed at reducing pressure in the portal system are indirect interventions. These include protocaveal shunting, reduction of splenic blood flow, intrahepatic portosystemic shunting.
With regard to liver transplantation, this is a very difficult operation that can be performed with persistent ascites. But, as a rule, finding a donor for an organ transplant is a difficult task.
Abdominal laparocentesis for ascites
Laparocentesis of the abdominal cavity with ascites is a surgical procedure in which fluid is removed from the abdominal cavity by puncture. More than 4 liters of exudate should not be pumped out at a time, as this threatens the development of collapse.
The more often a puncture is performed with ascites, the higher the risk of developing inflammation of the peritoneum. In addition, the likelihood of the formation of adhesions and complications from the procedure increases. Therefore, with massive ascites, it is preferable to install a catheter.
Indications for laparocentesis are tense and refractory ascites. The fluid can be pumped out using a catheter, or it simply flows freely into a pre-prepared dish after the trocar is inserted into the abdominal cavity.
[Video] Laparocentesis procedure (removal of fluid from the abdominal cavity):