In the article, we consider the causes of ascites of the abdominal cavity.
It is a secondary condition, which is characterized by the accumulation of transudate or exudate in the free cavity of the peritoneum. Ascites is clinically manifested in the form of an increase in the abdomen, a feeling of fullness, shortness of breath and pain in the peritoneum. Diagnosis of the pathology includes CT, ultrasound, diagnostic laparoscopy, ultrasound scan with ascitic fluid analysis. In order to start the pathogenetic therapy of ascites, in any case, it is necessary to determine the cause that caused the accumulation of fluid. In ascites, symptomatic measures include the appointment of diuretics to the patient, as well as puncture elimination of fluid from the peritoneal cavity.
Ascites
Edema of the abdomen, it is abdominal dropsy or ascites, is able to accompany the course of the most extensive list of diseases in the field of gynecology, lymphology, gastroenterology, rheumatology, cardiology, oncology, endocrinology, urology. The accumulation of peritoneal fluid with this pathology is characterized by an increase in pressure inside the peritoneum, pushing the diaphragmatic dome into the chest cavity. At the same time, a respiratory pulmonary excursion is very limited, blood circulation, the activity of the heart and peritoneal organs are disturbed. Massive abdominal edema can also be accompanied by electrolyte defects and significant loss of protein. With ascites, in this way, heart and respiratory failure, severe metabolic disturbances can develop, due to which the prognosis of the main disease worsens.
Causes of ascites ascites
The serous cover of the peritoneal cavity is normal - this is the production of the peritoneum with an insignificant amount of fluid, which is required for the free movement of intestinal loops and prevention of possible bonding of organs. This exudate is again absorbed by the same peritoneum. Due to a number of diseases, the barrier, resorptive and secretory functions of the peritoneum are disturbed, which causes ascites.
More often, abdominal edema in men with cirrhosis.
With ascitic syndrome, the abdomen is usually enlarged evenly, the skin is taut. In many patients, blue patterns that resemble the head of a jellyfish can be seen on the abdominal wall . Their occurrence provokes portal hypertension and, as a result, the expansion of venous vessels. As the abdominal pressure increases, the navel bulges outward. Over time, in patients who suffer from ascites, a hernia of the umbilical ring is revealed. Edema of the abdomen with cirrhosis of the liver occurs in the last stages of the pathology.
In newborns, ascites is often observed with hemolytic disease of the fetus. At an early age - with exudative enteropathy, malnutrition, congenital nephrotic syndrome. Ascites can develop with various disorders of the abdominal cavity:
- diffuse peritonitis of tuberculous, parasitic, fungal, non-specific etiology;
- pseudomyxoma;
- abdominal mesothelioma;
- peritoneal carcinosis due to cancer of the stomach and large intestine, ovaries, endometrium or breast.
Ascites is a pathology that can become a sign of polyserositis (that is, simultaneous pleurisy, pericarditis and dropsy of the peritoneum), which is observed with systemic lupus erythematosus, rheumatism, uremia, rheumatoid arthritis, Meigs syndrome (including the inclusion of hydrothorax, ascites and fibroid )
Ascites is often caused by pathologies that occur with portal hypertension - high pressure of the portal hepatic system (portal vein with ducts). Abdominal edema and portal hypertension can develop due to cirrhosis of the liver, alcoholic hepatitis, hepatosis; thrombosis of the liver veins caused by liver cancer, blood diseases, hypernephroma, widespread thrombophlebitis, etc .; thrombosis (stenosis) of the inferior vena cava or portal vein; stagnation of veins with right ventricular failure.
Protein deficiency
Ascites can develop due to protein deficiency, kidney disease (chronic glomerulonephritis, nephrotic syndrome), myxedema, heart failure, lymphostasis, due to compression of the lymphatic duct of the sternum, difficulty in the outflow of lymph from the peritoneal cavity, lymphangiectasias, gastrointestinal diseases (Crohn’s disease, pancreatitis diarrhea).
The reasons for the increase in the abdomen should be determined by the doctor. The pathogenesis of ascites is thus based on a complex set of hemodynamic, inflammatory, water-electrolyte, hydrostatic and metabolic defects, as a result of which the interstitial type fluid is sweated and accumulated in the peritoneal cavity.
Symptoms of ascites
Edema of the abdomen, depending on the reasons, can develop gradually when it builds up over several months, or suddenly. The patient usually pays attention to an increase in body weight, a change in the size of clothes or difficulty in fastening the belt.
Clinical symptoms of ascites are characterized by a feeling of fullness in the abdomen, abdominal pains, heaviness, flatulence, belching and heartburn, nausea. The abdomen, as the volume of fluid increases, increases in size, the navel protrudes. In the standing position - the stomach is saggy, in the supine position - flattened, swells in the side sections (the so-called "frog stomach"). If the peritoneal effusion is characterized by a large volume, swelling on the legs, shortness of breath, difficulty in movement, especially the tilts and turns of the body, appear. A strong increase in pressure inside the peritoneum with ascites can lead to femoral or umbilical hernias, hemorrhoids, varicocele and prolapse of the rectum.
Tuberculous peritonitis
In tuberculous peritonitis, ascites is caused by secondary infection of the peritoneal cavity due to intestinal or genital tuberculosis. For tuberculous ascites, fever, weight loss, and symptoms of general intoxication are also characteristic. In addition to ascitic fluid, lymph nodes along the intestinal mesentery are diagnosed in the peritoneal cavity. The exudate, which was obtained with tuberculous ascites, has a density of more than 1016, and the protein contains from 40 to 60 g / l, the sediment, including endothelial cells, red blood cells and lymphocytes, contains tuberculous mycobacteria, a positive Rivalt reaction.
Swelling of the abdomen with cancer is very common. If ascites accompanies peritoneal carcinosis, it is characterized by many enlarged lymph nodes, palpable through the front wall of the peritoneum. The main complaints with this form of ascites are diagnosed by the location of the primary tumor. Peritoneal effusion in almost all cases has a hemorrhagic character, sometimes atypical cells are in the sediment.
In patients with Meigs syndrome, ovarian fibroma is determined (in some cases, malignant ovarian tumors), hydrothorax, and ascites. Pronounced shortness of breath and abdominal pain are characteristic. Right ventricular heart failure , occurring along with ascites, is expressed by swelling of the feet and legs, acrocyanosis, pain in the right hypochondrium, hepatomegaly, hydrothorax. Ascites in renal failure is associated with diffuse edema of the subcutaneous tissue and skin - anasarca.
Collar vein thrombosis
Ascites appearing against the background of portal vein thrombosis has a persistent character, and is also accompanied by obvious pain syndrome, mild hepatomegaly, splenomegaly. Due to the occurrence of collateral circulation, extensive bleeding from hemorrhoidal nodes or varicose veins of the esophagus often appears. In peripheral blood, thrombocytopenia, leukopenia, and anemia are determined.
Ascites is an ailment that accompanies portal intrahepatic hypertension, characterized by moderate hepatomegaly, muscle dystrophy. On the skin of the abdomen, the expansion of the network of veins in the form of a “jellyfish head” is clearly visible. Persistent ascites in postrenal portal hypertension is accompanied by jaundice, vomiting, nausea and severe hepatomegaly.
There is also abdominal edema in heart failure. In sedentary patients with heart disease, fluid accumulation is observed in the abdomen, sacrum, sides, and pelvic organs. Although swelling is considered the most characteristic sign of heart failure, it is not the only one. Patients have shortness of breath and tachycardia, which indicates a neglect of pathology.
In protein deficiency, ascites is most often insignificant; pleural effusion, peripheral edema are noted . In rheumatic diseases, polyserosites are expressed by specific skin symptoms, the presence of fluid in the pleural cavity and pericardium, ascites, arthralgia and glomerulopathy. With violations of the outflow of lymph (chylous ascites), the size of the abdomen quickly increases. Ascitic fluid of a milky hue, a pasty consistency, lipoids and fats are determined in it during laboratory research. The volume of fluid in the peritoneal cavity with ascites can reach 5-10 or even 20 liters.
Swollen abdomen in older people is much more common than in young people.
Diagnostic Features
First of all, it is necessary to exclude other possible causes of an increase in the size of the abdomen - ovarian cysts, obesity, tumors of the peritoneal cavity, pregnancy, etc. To diagnose the pathology and its source, abdominal palpation and percussion, peritoneal MSCT, ultrasound of the lymphatic and venous vessels, ultrasound of the peritoneal cavity, liver scintigraphy, ascitic fluid examination, diagnostic laparoscopy are performed.
How to determine abdominal edema is interesting to many.
In ascites, percussion of the abdomen is distinguished by dullness of sound, as well as a movement of the border of dullness during a change in body position. If you put your palm on the side of the abdomen, you can feel the jolts (a sign of fluctuation) when you tap your fingers on the opposite surface of the abdomen. Thanks to a panoramic radiography of the peritoneal cavity, ascites can be identified if the amount of free fluid is more than half a liter.
In ascites from laboratory tests, an analysis of the coagulogram, levels of IgG, IgM, IgA, biochemical liver tests, the degree of general analysis of urine are carried out. In patients with portal hypertension, endoscopy is prescribed to detect altered varicose veins of the stomach or esophagus. With fluoroscopy of the sternum, fluid in the pleural cavities, a high state of the phrenic floor, and a limitation of pulmonary respiratory excursion can be determined.
In the process of ultrasound of the organs of the peritoneal cavity with ascites, the state and size of the tissues of the spleen and liver are determined, the processes of tumor and inflammation of the peritoneum are excluded. Thanks to hepatoscintigraphy, absorption and excretory activity of the liver, its structure and size, and the severity of cirrhotic disorders are determined. Dopplerography makes it possible to assess the vascular blood flow of the portal system. To assess the condition of the splenoportal bed, selective angiography - splenoportography (portography) is performed.
All patients with ascites detected for the first time undergo diagnostic laparocentesis of the intake and analysis of the nature of the fluid: establishing the cellular composition, density, protein content, as well as bacteriological culture. If the case of ascites is difficult to differentiate, a diagnostic laparotomy or laparoscopy with targeted abdominal biopsy is prescribed.
Ascites treatment
With pathogenetic therapy of ascites, it is necessary to eliminate the source of its development, that is, the primary disease. To reduce the symptoms of ascites, a limitation of fluid intake, a salt-free diet, and diuretics (Furosemide, Spironolactone under the guise of potassium drugs) are prescribed, water-electrolyte metabolism defects are corrected, and portal hypertension is reduced by antagonists of ACE inhibitor receptors and angiotensin II. At the same time, hepatoprotectors are used, as well as intravenous administration of protein preparations (albumin solution, native plasma).
Many are interested in what Furosemide is prescribed for.
It is a strong and fast-acting diuretic (diuretic). It should be taken in a minimum dosage, which will give the desired effect. "Furosemide" is usually prescribed for edema associated with:
- heart disease
- congestion in the large and small circle of blood circulation;
- hypertensive crisis;
- impaired renal function (nephrotic syndrome);
- liver diseases.
The drug should be monitored by a doctor because of possible side effects, as well as the risk of overdose, which will lead to dehydration, impaired cardiac activity, a dangerous decrease in blood pressure and other dangerous consequences.
Why "Furosemide" is prescribed to patients, it is now clear.
In ascites, which is characterized by resistance to ongoing medical treatment, abdominal laparocentesis (paracentesis) is used, that is, puncture removal of fluid from the peritoneal cavity. For one puncture, it is advisable to evacuate no more than four to six liters of ascitic fluid due to the possibility of collapse. If punctures are often repeated, conditions are created for abdominal inflammation, the formation of adhesions, and the likelihood of complications of further sessions of laparocentesis is increased. That is why, with prolonged excretion of fluid with massive ascites, a permanent peritoneal catheter is installed.
Interventions that provide conditions for the direct excretion of peritoneal fluid are partial deperitonization and peritoneovenous shunt of the walls of the peritoneal cavity. In ascites, indirect interventions are operations that reduce pressure in the portal system. These include manipulations with the application of various types of portocaval anastomoses (intrahepatic transjugular portosystemic bypass, portocaval bypass, reduction of splenic blood flow), as well as lymphovenous anastomosis. In some cases, with refractory ascites, splenectomy is performed.
- Therapeutic laparocentesis. In addition to the fact that this procedure requires a lot of time for both the patient and the doctor, it leads to the loss of opsonins and protein, while diuretics do not affect their content. A decrease in opsonin levels may increase the risk of primary peritonitis.
The problem of the advisability of introducing colloidal solutions to the patient after the elimination of a large volume of ascitic fluid has not yet been resolved. The cost of one albumin infusion ranges from $ 120-1250. Changes in serum creatinine, electrolytes, and plasma renin in patients who have not been infused with colloidal solutions do not seem to have clinical significance and do not lead to an increase in the number of complications and mortality.
- Bypass surgery. At about five percent, the usual dosages of diuretics become ineffective, while increasing the dose causes impaired renal function. In such situations, shunting is prescribed. In some cases, side-by-side portocular shunting is performed, but it is characterized by increased mortality. Denver or peritoneovenous shunting, for example, according to Le Win, can improve the condition of some patients. In most cases, a person still needs to take diuretics, but their dosage can be reduced. Among other things, the blood flow of the kidneys improves. Thirty percent of patients experience shunt thrombosis and need to be replaced. Peritoneovenous shunting is contraindicated in cases of heart failure, sepsis, bleeding from varicose veins and a history of malignant neoplasms. The survival of patients and the frequency of complications in people with cirrhosis of the liver after this form of bypass surgery is determined by the degree to which renal and hepatic function is impaired. The best results were obtained in patients with persistent ascites, but at the same time, quite intact liver function. Currently, peritoneovenous shunting is prescribed only to a few patients who have no results either laparocentesis or diuretics, or when diuretics are ineffective in people who need to get a specialist too long to undergo treatment laparocentesis once every two weeks.
Also, with persistent ascites, orthopedic liver transplantation can be performed if there are other indications for it.
Prognosis for pathology
The presence of swelling of the abdomen significantly complicates the course of the underlying disease and worsens the prognosis. In ascites itself, complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, and bleeding can occur.
Adverse prognostic factors in patients with ascites are advanced age (over 60 years), renal failure, hypotension (less than 80 mm Hg), hepatocellular carcinoma, liver cirrhosis, diabetes mellitus, liver cell failure, etc. With ascites, the two-year survival rate is approximately fifty percent.
The likelihood of relapse and possible complications
It must be remembered that due to ascites, in any case, the course of the main disease worsens, causing hydrothorax, respiratory failure, hernia, intestinal obstruction and many other complications. Even if ascites can be cured, you need to be very careful about your health, since there is always a chance of relapse. That is why, even after getting rid of ascites, you must adhere to a diet prescribed by a specialist.
If a person wonders why the stomach has become large, he needs to go to the doctor juicy.
The accumulation of fluid in the peritoneal cavity can cause severe discomfort, however, even before this happens, other signs appear. They should not be ignored, you must always consult a doctor.