As a result of various deviations between the two layers of this structure, a gradual accumulation of a large volume of liquid begins, which in its content is very similar to blood plasma.
In newborns, ascites develops in case of hidden blood loss or in the presence of a hemolytic disease in the fetus. In children under three years of age, ascites is usually associated with liver disease, but may also be the result of exudative enteropathy, chronic eating disorders, and nephrotic syndrome.
The emergence of ascites contribute to violations of water-salt metabolism.
Causes of Ascites
Most often, ascites occurs when:
- kidney disease
- heart failure
- nutritional dystrophy,
- cirrhosis of the liver.
In addition, ascites occurs as a result of lesions of the lymphatic thoracic duct, peritoneum (tuberculosis, cancer seeding, and so on) and as a result of compression of the trunk portal vein of the liver or thrombosis of its branches.
Mechanisms of onset and development of ascites
The fluid in the peritoneal cavity can be a filtrate of blood serum or lymph (transudate), or it can be an exudate formed during inflammation of the peritoneum itself. The fluid in the abdominal cavity can be serous, hemorrhagic, chyle, purulent. In most cases, it is serous.
Hemorrhagic fluid occurs most often in tuberculosis, malignant tumors, scurvy. When ascitic fluid has a milky appearance, they talk about chylous ascites.
It is formed due to the entry into the peritoneal cavity of a significant amount of lymph from the thoracic lymphatic duct or from the lymphatic vessels of the abdominal cavity. Chylous fluid is sterile, contains a large number of lymphocytes, and upon standing is divided into layers.
The accumulation of fluid in the abdominal cavity (sometimes more than 20 liters) leads to an increase in intra-abdominal pressure and the displacement of the diaphragm into the chest cavity.
As a result, the respiratory movements of the lungs are significantly limited (up to the development of respiratory failure), heart activity is disturbed, resistance to blood flow in the abdominal organs, whose functions are also disturbed, increases.
The concentration of protein in serous ascitic fluid is relatively small, but its total loss with massive ascites can be significant, especially with frequent repeated removal of fluid by puncture of the abdominal cavity (with loss of protein combined with loss of salt), which leads to the development of protein deficiency.
Pathogenesis of ascites in liver cirrhosis. Matter:
- portal hypertension
- increased lymph formation in the liver,
- sodium retention to the kidneys.
The process of peripheral arterial vasodilation caused by endotoxins and cytokines initiates, nitrogen oxide serves as a mediator, as a result, the “effective” plasma volume is reduced, compensatory sodium retention mechanisms are activated by the kidneys to maintain constant intravascular volume. In severe ascites, the content of atrial natriuretic factor in the blood plasma is high, but not enough to cause natriuresis.
The development of ascites is considered a prognostic unfavorable sign and significantly complicates the course of the underlying disease. Ascites may be complicated by bleeding, peritonitis, failure of the spleen, liver, brain damage due to edema, heart dysfunction. On average, the percentage of mortality in patients with severe ascites reaches 50%.
What it is?
Ascites is an accumulation of fluid in the abdominal cavity, which is accompanied by a progressive increase in the abdomen and an increase in the weight of the patient. This fluid is usually non-inflammatory in nature, that is, it is a transudate. Its amount can vary significantly - from a few hundred milliliters to 15-20 liters.
The peritoneum, which lines the inside of the abdominal cavity and wraps up a number of its organs, normally secretes a small amount of serous fluid, in its composition similar to blood plasma. This fluid is necessary so that the internal organs, which are rather compactly located in the abdominal cavity, do not stick together, and that there is no friction between them. During the day, serous fluid is excreted and absorbed by the peritoneum many times. Its increased production and deterioration of suction and lead to the accumulation of free fluid in the stomach.
This is a common mechanism of ascites, with a number of pathologies, it may differ. The way excess fluid accumulates in the stomach can be vividly illustrated by the example of liver cirrhosis:
- normal liver cells are replaced by scars, because of this, the liver produces less protein - in particular, albumin. Reducing its quantity means increased plasma dilution. To equalize the degree of dilution of plasma, the fluid exits from the vessels into the tissues and body cavities - including the abdominal, causing the appearance of ascites,
- on the other hand, in the cirrhotic liver pressure of the scar tissue on the vessels is observed - the fluid from them is literally squeezed into the tissues and cavities.
Ascites is dangerous because it creates a so-called vicious circle - the process of excessive fluid formation and impaired suction starts, but it is difficult to get out of this state, because the breakdown of some mechanisms provokes the breakdown of others, which further contribute to the growth of ascites:
- if the veins are squeezed, the body tries to relieve them, and the excess fluid is sent to the lymphatic system, but it can also cope with the excess load to a certain level - then the lymph pressure rises, fluid from the lymphatic vessels seeps into the abdominal cavity,
- as the fluid from the blood vessels rushes into the abdominal cavity, this leads to a decrease in blood volume and its pressure. To compensate for this condition, the body produces more hormones. But because of the increased production of hormones, blood pressure increases. The fluid is poorly retained in the vessels and rushes into the abdominal cavity - ascites increases.
When a tumor or inflammation is damaged, some shell begins to produce more fluid than it can suck back - this causes ascites. Besides, the tumor and the edematous tissues, due to inflammation, put pressure on the lymphatic vessels, not allowing the lymph to move freely through them, the liquid part of the lymph rushes into the tissues and cavities - including the abdominal one.
If heart failure has developed, the blood flow is disturbed not only in the heart, but also in the veins of the liver and peritoneum. Plasma from the vessels passes into the abdominal cavity. The peritoneum is not ready to absorb additional amount of fluid - ascites occurs.
Symptoms of ascites
Depending on the disease provoking, signs of ascites can develop both suddenly and gradually, over several months. Thus, when the thrombus of the portal vein is blocked, the amount of free fluid in the abdominal cavity increases very quickly, and with protein starvation - gradually. Symptomatology occurs if the stomach accumulated from 1 liter of fluid.
The main signs of ascites are:
- stomach ache,
- feeling of bursting
- an increase in the abdomen
- weight gain
- difficulties in physical activity - in particular, when trying to lean forward,
- dyspeptic disorders
If the abdomen grows in size very quickly, it means that the lymphatic vessels have been transferred.
Dyspeptic changes that occur with ascites are due to the fact that an increasing amount of free fluid puts pressure on the digestive organs, which prevents them from performing their functions. There are signs such as:
- difficulty in the discharge of gases (flatulence),
- with progression - difficulty in the act of defecation (emptying the large intestine from the stool).
Nausea and vomiting are observed if the pressure in the portal vein of the liver due to obstruction of the subhepatic veins increases, which causes the onset of ascites.
Shortness of breath in the initial stages of ascites occurs during exercise. As the amount of free fluid in the abdominal cavity increases, it puts pressure on the lungs and heart, causing shortness of breath and at rest.
Puffiness is due to mechanical squeezing of the veins and disruption of blood flow in them with subsequent release of fluid into the tissue. With ascites, the legs are mostly swollen; in men, the scrotum can sometimes swell.
If ascites has arisen due to the tuberculous process, then there are characteristic signs of intoxication (poisoning of the body with the products of the life of the tubercle bacillus). It:
- general weakness
- unexplained fatigue that occurs even at rest,
- heart palpitations
- weight loss. The patient in this case looks very characteristic: thin arms and legs and a big belly.
If ascites has arisen due to protein deficiency, then it is not very pronounced, a significant increase in the abdomen is not observed. But for this state are characteristic:
- swelling of the upper and lower extremities,
- shortness of breath - it occurs because the fluid, except for the abdominal cavity, accumulates in the pleural, pressing the heart and lungs and thereby impairing their work.
Diagnosis of Ascites
Complaints of the patient with ascites are quite characteristic. Even more characteristic is the data of the physical examination of the patient - examination, palpation of the abdominal wall, tapping and listening to the abdomen with a phonendoscope. According to their totality, diagnosis of ascites is not difficult.
Inspection data is as follows:
- the abdomen is enlarged
- if a person is standing, then the stomach has the shape of a ball (often similar to the stomach during pregnancy), the lower part may hang, in the supine position, because of the draining of the liquid, it is spread in the lateral parts ("frog's belly"),
- navel bulges outward. Bulging appears gradually and indicates the progression of the process
- white stretch marks appear on the skin of the abdomen, similar to stretch marks in women in late pregnancy,
- perhaps the expansion of the subcutaneous veins - they can be seen if the accumulation of free fluid in the abdominal cavity is triggered by an increase in pressure in the portal vein (an important feature in determining the cause of ascites). Such dilated veins can be seen on the front and side surfaces of the abdomen,
- yellowness of the skin - if ascites is caused by increased pressure in the portal vein due to obstruction of the subhepatic vessels.
The following sign is indicative: if one palm is placed on the side of the patient and the fingers of the other hand are pushed on the other side, then fluctuations (“waves”) of fluid inside the abdomen will be felt.
If you do the tapping of the abdomen, the sound will be dull, as, for example, on a tree - in the lower abdomen, if the patient is standing, and in the lateral sections, if it lies.
With a significant accumulation of fluid in the abdominal cavity, when listening to the abdomen, it is possible to ascertain the attenuation of intestinal noise.
Patient complaints, studying his medical history (for example, the presence of liver or cardiovascular diseases) and physical examination data are often enough to diagnose ascites. Instrumental and laboratory research methods are used additionally to confirm the diagnosis and determine the cause of ascites.
From instrumental methods in the diagnosis of ascites used such as:
- ultrasound examination of the abdominal organs (ultrasound) - using it to detect fluid in the abdominal cavity, and can also determine the cause of ascites (cirrhotic liver damage, swelling of the peritoneum, etc.),
- abdominal laparoscopy - an endoscope (flexible apparatus with integrated optics) inserted into the abdominal cavity through a small hole allows the eye to see fluid in it and changes in internal organs that could provoke ascites, as well as make fluid for laboratory analysis, which will help identify the nature of ascites,
- laparocentesis - a puncture is made in the abdominal wall under local anesthesia, if there is a liquid in the abdominal cavity, it follows, this confirms the diagnosis of ascites. Free fluid obtained during laparocentesis is examined in the laboratory,
- Ultrasound of the chest - it can be used to analyze changes in the heart that can provoke ascites, and to identify fluid in the pleural cavities as an additional diagnostic sign,
- computed tomography of the abdominal cavity organs (CT) - with its help you can see the fluid in the abdominal cavity, if it is difficult to notice when conducting other research methods,
- magnetic resonance tomography of the abdominal organs (MRI) - its capabilities are the same as those of computed tomography,
- general abdominal radiography - it can be used to identify free fluid in the abdominal cavity, if its volume is 0.5 liters or more,
- chest X-ray - it is used to detect changes in the lungs (for example, tuberculosis that can provoke ascites), the heart and the pleural cavity, which may be the causes of ascites (for example, heart failure),
- hepatoscintigraphy - the study of the liver using radionuclides, which helps in the evaluation of a cirrhotic organ lesion, which caused ascites,
- angiography - a contrast agent is introduced into the vessels and the changes in them are studied. The method is used if ascites has arisen due to vascular problems.
In the diagnosis of ascites, the following laboratory test methods are highly informative:
- biochemical analysis of blood - determine the level of proteins, AST (liver enzyme), urea and creatinine (substances that characterize the excretory ability of the kidneys), potassium, sodium, and so on. The changes in these indicators determine the failure of which organs and systems could lead to ascites,
- coagulogram - it is used to study the characteristics of the blood coagulation system, which suffers from liver cirrhosis,
- determination of the level of α-fetoprotein in venous blood - using this method it is possible to detect liver cancer, which can provoke the occurrence of ascites,
- microscopic examination of ascitic fluid — first of all, for the presence of tumor cells that provoked ascites.
In addition, if treatment is started, the daily dynamics (changes) of the patient's weight should be monitored, for which the patient is periodically weighed.. In 24 hours, he should lose about 500 grams. It should also be borne in mind that the amount of fluids taken (in the form of tea, juices, soups, and so on) should be slightly larger than the amount released (at normal body and air temperatures).
Free fluid is easy to remove from the abdominal cavity - but the causes of ascites remain. therefore A complete treatment of ascites is the treatment of diseases that provoked its occurrence.
Regardless of what provoked ascites, the common uses are as follows:
- bed or half-bed (with getting out of bed only in case of physiological need) mode,
- restriction, and in advanced cases - the complete elimination of sodium from food. Achieved by limiting (or excluding) the use of salt.
If ascites has arisen due to cirrhosis of the liver, then with a decrease in the amount of sodium in the blood, the intake of liquids in different forms (tea, juices, soups) is limited to 1 liter.
Drug therapy depends on the disease that provoked ascites. General purpose, regardless of the cause of ascites, are diuretic drugs. It can be either their combination with potassium preparations, or potassium-saving diuretics. Also prescribed:
- in case of liver cirrhosis - hepatoprotectors (drugs that protect the liver cells),
- with a low amount of protein in the blood - protein preparations that are administered intravenously. As an example - albumin, fresh frozen plasma (it is injected, if ascites is observed violations of the blood coagulation system),
- in case of cardiovascular failure - drugs that support the work of the heart (they are selected depending on what the cause of the failure)
Surgical treatment of ascites is used for:
- significant accumulation of free fluid in the abdominal cavity,
- if conservative methods show low performance or do not show it at all.
The main surgical methods used for ascites are:
- laparocentesis — a wall of the abdomen is pierced; a drainage tube is inserted into the abdominal cavity through which fluid flows out. When a large volume of fluid is removed, it should be taken in portions, so as not to decompose the internal organs. Often the drainage tube is left in the stomach for several days,
- intrahepatic shunting - creating a message between the hepatic and portal veins. This will relieve the bloodstream, and the blood pressure will equalize, so that the liquid will no longer leave the vessels,
- liver transplantation (in case of its defeat).
Prognosis for ascites
The prognosis for both health and life depends on the disease that provoked ascites. It worsens when:
- over 60 years old
- lowering blood pressure
- loss of protein (in particular, if the amount of albumin in the blood is below 30 grams per liter),
- diabetes mellitus
- liver cancer,
- ascites, resistant to the use of diuretic drugs.
In most cases, the presence of ascites means that the disease that provoked it is running. 50% of patients with ascites die within 2 years of its occurrence.. If a form that is insensitive to diuretic drugs has developed, half of the patients die within six months.
Kovtonyuk Oksana Vladimirovna, medical commentator, surgeon, medical consultant
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Liver disease is the most common cause of ascites. The accumulation of fluid in the abdominal cavity may occur with the defeat of its cells or due to compression of the portal vein.
Hepatic cells produce a large amount of substances every minute, including albumin, proteins, some vitamins (A, E, D, K), "healthy" cholesterol, blood-coagulants, etc. Protein produced by the liver is necessary for retaining fluid in the lumen of the vessels. It attracts water to itself, so that a healthy person does not have edema. When the cells are damaged, the amount of produced protein decreases, which is why the fluid begins to sweat through the vascular wall in the tissue and cavity (abdominal, thoracic, pericardial, etc.).
Also, ascites can be caused by compression of the portal (portal) vein. This is a large vessel that is located on the back surface of the liver, in a small tenderloin. With an increase in the body, the vein can be strongly compressed, which leads to an increase in blood pressure on its walls. Because of this, the fluid "pushes" through the vein and immediately enters the abdominal cavity.
The table below describes liver diseases in which there is a malfunction of cells, an increase in an organ, or all together. With the development of ascites, they must be eliminated first.
- Most painkillers of anti-inflammatory drugs (Ibuprofen, Diclofenac, Ketorolac and others),
- Some antimicrobials (rifampicin, tetracycline, isoniazid).
- Primary biliary,
- Secondary (occurring after other liver diseases),
Despite the large number of various liver diseases, the correct diagnosis can be made according to the patient's condition and the results of some studies. Which ones? Information on this is presented below.
The blood moves through the body due to the continuous work of the heart and blood vessels. In violation of the functions of the heart muscle - blood flow begins to slow down, which leads to its stagnation and the release of fluid in the organs and tissues. First of all, swelling occurs on the legs and arms. However, in severe heart failure, the liquid part of the blood can accumulate around the internal organs and in the abdominal cavity.
Ascites on the background of cardiovascular diseases can occur when:
Damage to the heart muscle. Due to the decrease in the number of working cells and their replacement by the connective tissue, organ failure may occur. Damage may result from:
- any form of coronary heart disease, including heart attack and angina,
- infections (endo-, peri-and myocarditis),
- autoimmune diseases (lupus erythematosus, scleroderma and others),
- amyloidosis is a metabolic disorder in the body, due to which the pathological protein (amyloid) is deposited in the walls of the organs,
- injuries and injured organ.
Overloading of the heart. Some diseases lead to increased pressure on the walls of the body and their stretching. Such an overload can occur due to a delay in blood in the ventricles / atria or with increased pressure in the vessels. The cause of overload can be:
- Hypertension, with late initiation of therapy or improper treatment. After the diagnosis, the patient must constantly take drugs that reduce pressure, and periodically visit the district therapist (1 time per year). In case of loss of control over the course of the pathology (with a constant-elevated pressure) - it is necessary to consult the doctor again,
- Arterial hypertension, which can occur with hormonal disorders (Itsenko-Cushing syndrome, hyperthyroidism, etc.), renal tissue damage, damage to the brain,
- Congenital and acquired malformations, such as unfinished interventricular / interatrial septum, stenosis or valve insufficiency, stenosis or coarctation (expansion) of the aorta, and others.
Cardiomyopathy. This is a group of genetic diseases in which the structure of the heart wall is disturbed. There are two options - either it becomes too thick (hypertrophic form), or thinner (dilatation form).
Heart failure is a condition that requires proper and timely treatment. The development of ascites in the pathology of the heart is always an unfavorable sign, indicating an insufficient amount of therapy or a severe course of the disease.
This body performs a large number of functions, one of which is the removal of excess fluid and toxins from the body. During the day, the kidneys filter about 180 liters of blood. With the defeat of the renal tissue, this process is disturbed, which leads to the accumulation of fluid in various parts of the body: on the legs and hands, on the face, in the cavities of the stomach, heart and internal organs.
This condition is aggravated by the constant loss of protein in the urine, which is caused by the destruction of the kidney filter. As the protein in the blood vessels becomes smaller, the arteries and veins cannot hold all the liquid part of the blood. As a result, the swelling becomes even larger and spreads throughout the body.
Not every kidney disease can cause such fluid retention. The following pathologies most often lead to the destruction of renal tissue and impaired filtration process:
- Glomerulonephritis. Under this term understand the whole group of diseases that combines several symptoms. The first is that they almost always lead to the destruction of the kidney filter and force the person to use hemodialysis (at the final stage). Secondly, glomerulonephritis is an autoimmune disease that develops due to the “error” of the body’s defense systems. As a result, blood cells begin to attack and destroy healthy kidney cells,
- Tubulo-interstitial nephritis (abbreviated - TIN). This is a disease in which components of the kidney filter (tubules) die. Most often, it occurs after poisoning with various toxins, including heavy metals, drugs, methanol and other substances. Also, cases of development of TIN were observed after severe viral diseases, radiation exposure, amid cancer of any organ,
- Diabetic nephropathy. Diabetes is not just elevated blood glucose. This is a serious illness that gradually affects the entire body, including the kidneys. In the absence of adequate treatment and constant sugar control, the kidney filter begins to slowly and irreversibly collapse, which can lead to widespread edema and ascites,
- Congenital malformations of the kidneys. Polycystic kidney disease, underdevelopment of the renal tissue, absence (agenesis / aplasia) of the kidney - all these conditions can cause a fluid retention in the patient’s body,
- Systemic disease. Lupus erythematosus, periarteritis nodosa, rheumatoid arthritis, systemic scleroderma are rare but serious diseases that damage the connective tissues of the human body, including the kidneys,
- Hypertonic disease. Constantly increased pressure negatively affects the work of all organs, but primarily on the heart and kidneys. Hypertension, which is not treated or treated incorrectly, inevitably leads to shrinkage of the kidneys and impairment of their functions.
Launched kidney disease is almost always difficult. In this case, ascites is only one of many symptoms. These patients develop edema throughout the body, worsening state of health, the work of the heart, brain and other organs.
Other causes of ascites
Eliminating the presence of diseases of the kidneys, heart and liver, as possible causes, it is necessary to proceed to assess the condition of other organs. The problem may be hiding in impaired lymphatic fluid drainage, a decrease in thyroid function, or damage to the peritoneum. In particular, accumulation of fluid in the abdominal cavity can occur with the following diseases:
- Carcinomatosis peritoneum. This term refers to the growth of cancer cells in the peritoneum - the membrane covering the intestinal loops. As a rule, the source of pathological cells is another organ in the stomach, affected by a malignant tumor (cancer or sarcoma),
- Tuberculosis of the peritoneum or mesenteric lymph nodes. Contrary to popular belief, this infection can affect not only the lungs, but also any other organs. After the development of the disease, Koch sticks can settle and develop throughout the body, including in the abdomen,
- Pronounced hypothyroidism. A decrease in thyroid function and a deficiency of its hormones can lead to the development of pronounced edema throughout the body. There is no exception and the abdominal cavity, in which a significant amount of fluid can accumulate,
- Lymphostasis in the abdomen. Narrowing or blockage of the lymphatic vessels is one of the causes of ascites. This pathology may occur due to compression of their tumor, with some parasitic diseases (eg, filariasis), after surgical operations on the abdomen and the use of radiation therapy.
The accumulation of fluid in the abdominal cavity is difficult to determine. An increase in the abdomen can occur not only in ascites, but also in cases of pancreatitis, intestinal paresis, intestinal obstruction, pregnancy, and a number of other conditions. Therefore, it is important to be able to distinguish free fluid in the abdomen from its distention, accumulation of feces, increase in other organs, etc. To do this, you can use the following simple tricks:
- Put your hands on the side surfaces of the abdomen. After that, one hand gently push the stomach 2-3 times. If the second hand felt a splash of fluid or its movement, then most likely the cause of an increase in the abdomen is ascites,
- Assess the shape of the abdomen in two positions: standing and lying down. If a person has a round shape of the abdomen and it hangs down a little while he is standing, but in the prone position, the stomach “spreads” and “flattens out” - you should suspect the presence of fluid.
Also, in addition to directly changing the abdomen, the patient may experience a number of other symptoms of abdominal ascites, due to fluid accumulation and an increase in intra-abdominal pressure. The most frequent of these include:
- Difficulty breathing, including dyspnea or wet cough,
- Frequent urge to urinate,
- Development of constipation
- Constant weakness and reduced performance.
However, it should be noted that a disease will be much easier and better diagnosed if a person with a suddenly enlarged stomach contacts a doctor. He will be able to more reliably examine, probe and “tap” the abdominal wall and, if necessary, refer the patient to an additional examination or hospital.
How to determine the cause of ascites
In the first section, a huge number of causes of this condition were given. To suggest a diseased organ and to determine the most likely disease that a person has, a comprehensive examination is necessary. It should begin with a thorough clarification of all complaints and possible harmful factors, and end with a specialized diagnosis. Below, we describe the principles of this diagnosis and how to find out the true cause of ascites.
Analysis of all complaints and harmful factors
To determine the affected organ, it is first necessary to find out whether a person has specific symptoms that indicate heart disease, kidney, liver, lymphatic vessels, etc. The manifestations of these diseases can be quite diverse, but they are characterized by some common features. The most characteristic of them, which help to make a diagnosis, are described in the table:
Ascites as a frequent companion of dangerous diseases
Under ascites in medicine understand the secondary pathological condition, which is characterized by accumulation of fluid in the abdominal cavity. Most often, ascites is caused by dysregulation of fluid metabolism in the body as a result of serious pathological conditions.
In a healthy body, there is always some fluid in the abdominal cavity, while it does not accumulate, but is absorbed by lymphatic capillaries. In various diseases of internal organs and systems, the rate of formation of fluid increases and the rate of its absorption decreases. With the development of ascites fluid becomes more and more, it begins to squeeze the vital organs. This contributes to the aggravation of the development of the underlying disease and the progression of ascites. In addition, since the main part of the fluid accumulates in the abdominal cavity, there is a significant decrease in the volume of circulating blood. This leads to the launch of compensatory mechanisms that hold water in the body. In a patient, the rate of urine formation and discharge is significantly slowed down, while the amount of ascitic fluid increases.
The accumulation of fluid in the abdominal cavity is usually accompanied by increased intra-abdominal pressure, impaired blood circulation and cardiac activity. In some cases, there is a loss of protein and electrolyte disorders that cause heart and respiratory failure, which significantly worsens the prognosis of the underlying disease.
In medicine, there are three main stages of development of ascites.
- Transient ascites. At this stage no more than 400 ml of fluid accumulates in the abdominal cavity. Identify the disease is possible only with the help of special studies. The functions of the organs are not impaired. Removal of symptoms of ascites is possible with the treatment of the underlying disease.
- Moderate ascites. In the abdominal cavity at this stage up to 4 liters of fluid accumulates. There is an increase in the abdomen of the patient. When standing, you can notice the bulging of the lower part of the abdominal wall. In the prone position, the patient often complains of shortness of breath. The presence of fluid is determined by percussion (knocking) or fluctuation symptom (vibrations of the opposite abdominal wall when tapped).
- Intense ascites. The amount of liquid at this stage can reach, and in some cases even exceed, 10–15 l. The pressure in the abdominal cavity rises and disrupts the normal functioning of vital organs. The patient’s condition is severe, and must be urgently hospitalized.
Separately, refractory ascites is considered, which is practically not amenable to treatment. It is diagnosed in the event that all types of therapy do not give results and the amount of fluid not only does not decrease, but constantly increases. The prognosis for this type of ascites is unfavorable.
Signs of pathology
One of the main external signs of abdominal ascites is an increase in the size of the abdomen. In the standing position of the patient, he may hang in the form of an apron, and in the supine position to form a so-called frog belly. Perhaps the protrusion of the navel and the appearance of stretch marks on the skin. With portal hypertension caused by an increase in pressure in the portal vein of the liver, a venous pattern appears on the anterior abdominal wall. This picture is called the “head of Medusa” because of the distant resemblance to the mythological Medusa Gorgon, on the head of which wrinkling snakes were placed instead of hair.
In the stomach, pain and a feeling of distention occur from within. A person has difficulty bending the body. The external manifestations also include swelling of the legs, arms, face, cyanosis of the skin. The patient develops respiratory failure, tachycardia. Constipation, nausea, belching, and loss of appetite are possible.
In laboratory and instrumental studies, the doctor confirms the diagnosis and establishes the cause of the ascites. For this, ultrasound, MRI, diagnostic laparocentesis and laboratory tests are performed. Using ultrasound, the presence of free fluid in the abdominal cavity and its volume, enlargement of the liver and spleen, expansion of the vena cava and portal vein, impaired kidney structure, the presence of tumors and metastases are detected.
MRI allows one or another tissue to be examined in layers, to detect even a small amount of ascitic fluid and to diagnose the underlying disease that caused ascites.
In addition, the doctor conducts research using palpation and percussion. Palpation helps to identify signs indicating a lesion of a particular organ (liver or spleen). Percussion is used directly to identify ascites. Its essence lies in tapping the abdominal cavity of the patient and the analysis of percussion sounds. In severe ascites, for example, a dull percussion sound is determined over the entire surface of the abdomen.
Laboratory blood tests show a decrease in the concentration of red blood cells, an increase in the number of leukocytes and ESR, possibly an increase in the concentration of bilirubin (in liver cirrhosis), proteins of the acute phase of inflammation. The initial analysis of urine in ascites may show a greater amount of urine of lesser density, since ascites causes abnormalities in the functioning of the urinary system. At the terminal stage, urine density may be normal, but its total amount is significantly reduced.
Principles of therapy
The general principles of treatment of ascites suggest primarily the treatment of the underlying disease. The treatment of ascites itself is aimed at removing fluid from the abdominal cavity and preventing relapse.
Patients with the first degree of ascites do not need medication and salt-free diets.
Patients with a second degree of ascites are prescribed a low-sodium diet and diuretic therapy. It should be carried out with continuous monitoring of the patient's condition, including the content of electrolytes in the serum.
Patients with a third degree of the disease carry out the removal of fluid from the abdominal cavity, and later diuretic therapy in combination with a salt-free diet.
Ascites usually indicates a serious disturbance in the work of the affected organs, but nevertheless it is not a fatal complication. With timely diagnosis and proper treatment, complete elimination of ascites fluid from the abdominal cavity and restoration of the functions of the affected organ are possible. In some cases, for example in cancer, ascites is able to progress rapidly, causing complications and even death of the patient. This is due to the fact that the main disease, which can cause serious damage to the liver, kidneys, heart and other organs, has a great influence on the course of ascites.
Other factors affect the prognosis:
- Degree of ascites . Transient ascites (first degree) is not an immediate threat to the life of the patient. In this case, all attention should be paid to the treatment of the underlying disease.
- Time to start treatment . If ascites are detected at the stage when vital organs are not destroyed or their functions are affected slightly, the elimination of the underlying disease can also lead to complete recovery of the patient.
The type and severity of the underlying disease also affects survival statistics for ascites. With compensated liver cirrhosis, 50% of patients are able to live from 7 to 10 years, and with decompensated - five-year survival does not exceed 20%.
In oncological diseases, ascites, as a rule, appears in the late stages, and the five-year survival rate is no more than 50% with timely treatment. The average life expectancy for such patients is 1–2 years.
With the wrong treatment, ascites can cause serious complications that worsen the prognosis:
- swelling of the brain
- cardiac dysfunction,
- severe respiratory failure.
Ascites relapses can also occur as side effects with improper treatment. Recurrence is very dangerous, because in most cases, ascites that are not curable can be fatal.
Conservative treatment of abdominal ascites
Conservative or symptomatic treatment of ascites is used in cases when abdominal ascites is at an early stage of development or as a palliative therapy in oncology and the inappropriateness of using other methods.
In all cases, the main task of treatment is to excrete ascitic fluid and maintain the patient's condition at a certain level. To do this, it is necessary to reduce the amount of sodium entering the body and increase its excretion in the urine.
Positive results can only be achieved with an integrated approach, following a diet, controlling weight changes and taking diuretic drugs.
Main principles of diet for ascites, the following:
- At least salt. Its excess consumption leads to the development of edema, and consequently, ascites. Patients are advised to limit the intake of salty foods.
- Minimum liquid . With moderate or intense ascites, the norm should be no more than 500–1000 ml of liquid in its pure form per day.
- Minimum fat . The consumption of food with a large amount of fat leads to the development of pancreatitis.
- Enough protein in the diet. It is protein deficiency that can lead to edema.
It is recommended to eat low-fat varieties of meat and fish, low-fat cottage cheese and kefir, fruits, vegetables, greens, wheat cereals, compotes, jelly. Cooking better steamed or baking in the oven.
Prohibited fatty meat and fish, fried foods, smoked meats, salt, alcohol, tea, coffee, spices.
In the treatment of ascites, it is necessary to control the dynamics of weight. At the start of a salt-free diet, a daily weighing is done during the week. If a patient has lost more than 2 kg, diuretic drugs are not prescribed to him. With a weight loss of less than 2 kg, drug therapy is initiated over the next week.
Diuretic drugs help to remove excess fluid from the body and contribute to the transition of the fluid from the abdominal cavity into the bloodstream. The clinical manifestations of ascites are significantly reduced. The main drugs used in therapy are furosemide, mannitol and spironolactone. On an outpatient basis, furosemide is administered intravenously no more than 20 mg 1 time every two days. It removes fluid from the vascular bed through the kidneys. The main disadvantage of furosemide is the excessive excretion of potassium from the body.
Mannitol is used together with furosemide, because their action is combined. Mannitol removes fluid from the extracellular space into the bloodstream. Assigned to 200 mg intravenously. However, in the outpatient setting it is not recommended.
Spironolactone is also a diuretic, but it can prevent excessive excretion of potassium.
Additionally prescribed drugs that strengthen the vascular walls (vitamins, diosmin), agents that affect the blood system ("Gelatinol", "Reopoliglyukin"), albumin, antibiotics.
Surgery for ascites is indicated in cases where fluid accumulation cannot be eliminated with the help of conservative treatment.
Therapeutic laparocentesis with ascites (puncture of the anterior abdominal wall) is able to bring large volumes of fluid - from 6 to 10 liters at a time. Conduct the procedure under local anesthesia with a preliminary emptying of the bladder. The patient assumes a half-sitting or recumbent position. The puncture is made in the midline of the abdomen between the navel and the pubic bone. With a scalpel, a skin incision is made, through which a special instrument, the trocar, is inserted into the abdominal cavity. Through it liquid is withdrawn in the right amount. After the procedure, the wound is sutured. Laparocentesis with ascites can only be performed in a hospital, since it is necessary to comply with the norms of antiseptics and possession of the method of operation. To simplify the procedure for those patients for whom laparocentesis is required periodically, it is carried out through a permanent peritoneal port.
Another effective surgical procedure is omentohepatofrenopeksiya . It consists in filing the omentum to the pre-treated areas of the surface of the diaphragm and liver. Due to the occurrence of contact between the liver and gland, it becomes possible to absorb ascites fluid from adjacent tissues. Additionally, the pressure in the venous system and fluid flow into the abdominal cavity through the walls of blood vessels is reduced.
TIPS - transjugular intrahepatic portosystemic shunting - allows to decompress the portal system and eliminate ascitic syndrome. In general, TIPS is performed with refractory ascites, which is not amenable to drug therapy. During the TIPS procedure, a conductor is inserted into the jugular vein before it enters the hepatic vein. Then a special catheter is guided through the guide to the liver itself. Using a long curved needle in the portal vein, a stent is inserted to create a channel between the portal and hepatic veins. The blood is sent to the hepatic vein with reduced pressure, which leads to the elimination of portal hypertension. After performing TIPS in patients with refractory ascites, a decrease in fluid volume is observed in 58% of cases.
Despite the fact that ascites and the diseases causing it are quite serious and difficult to treat, timely complex therapy can significantly increase the chances of recovery or improve the quality of life of incurable patients. Treatment of ascites is necessary only under the supervision of a physician, since the complexity of the underlying disease rarely allows to do with home or folk methods. Especially it concerns the ascites caused by oncology.
Conservative treatment of ascitic syndrome
It must be complex, remove ascitic fluid. For this you need:
- create a negative sodium balance,
- to increase the excretion of sodium in the urine.
Creating a negative balance is achieved by limiting sodium intake from food into the body (salt up to 3 g per day). It is proved that a completely salt-free diet adversely affects the metabolism of proteins in the body. Increased excretion of sodium. The prescription of diuretic drugs is practiced (potassium savers and potassium saves).
The pharmacological industry does not have a single diuretic (diuretic) drug for the treatment of ascites, which would fully satisfy clinicians in all respects.
The use of the most "powerful" diuretic Lasix (Furosemide) is limited because it promotes the excretion of potassium from the body. He is prescribed under the cover of potassium preparations (Panagin, Asparkam, polionic mixtures, Potassium Orotate) and control of the body's electrolyte balance.
Lasix is administered intramuscularly or intravenously throughout the week, then the drug is administered in tablets several times a week.
From potassium-sparing diuretics, spironolactones (Veroshpiron) are used according to the schedule - 4 doses throughout the day. The effect develops after 2-3 days. Spironolactones also have a lot of side effects - in women, menstrual dysfunction, in men, gynecomastia (breast enlargement), decreased libido (sexual desire) in both sexes.
Doses are calculated individually, it all depends on how the patient feels, what other diseases he has. It is necessary to take into account the fact that high dosages threaten the development of side effects: an imbalance of electrolytes in the body, the development of encephalopathy (not inflammatory diseases of the brain), dehydration.
It is important to remember that diuretics reduce not only ascites, but also contribute to the removal of fluid from other tissues. While there is swelling it is not dangerous, but if you continue to receive diuretics after they disappear, then the following complications may develop:
- decrease in circulating blood volume,
- the emergence of functional renal failure due to a decrease in renal blood flow,
- development of electrolyte imbalance disorders up to seizures,
Abolish diuretics preferably in steps. At the beginning of Lasix, then Veroshpiron.
Now began to use for the treatment of ascites, drugs such as Captopril, Enalapril, Fozinopril. Their action is based on enhancing the excretion of sodium from the body and increasing the amount of daily urine. At the same time they detain potassium in the body. This is especially true for cases of ascitic syndrome that has developed on the background of liver cirrhosis.
After the disappearance of edema, it is recommended to follow a diet with a decrease in the intake of food with salt. Contraindications for the appointment of diuretic drugs are the presence of such pathologies in the patient as:
- renal failure
- severe electrolyte imbalance,
- hepatic encephalopathy.
In the conservative treatment of ascitic syndrome is the observance of bed rest.It is proved that it improves venous renal and portal blood flow, thereby reducing the formation of toxic metabolites (substances) in the liver, and the functioning of the lymphatic system is improving.
While improving overall well-being, a half-bed mode is recommended, otherwise the risk of developing congestion and bedsores is large enough. Along with bed rest for severe ascites, it is recommended to limit fluid intake (on average, 1 liter per day).
Surgical treatment of ascitic syndrome
Often used surgical manipulation, which is called laparocentesis. The goal is to remove excess volume of ascitic fluid from the abdominal cavity. The indications for its conduct is the accumulation of a large volume of ascitic fluid or the absence of the effect of prescribing diuretic drugs. Laparocentesis is most often performed in a sitting position under local anesthesia.
A special tool (trokar) makes a puncture in the lower part of the anterior abdominal wall of the abdomen, through which excess fluid is removed. How much fluid will be removed at one time, or a permanent catheter will be installed, decides the attending physician. It is important to remember that the removal of large volumes of liquid at a time (more than 5-6 liters) can cause a number of complications. The most severe - a sharp drop in blood pressure, cardiac arrest.
The causes of ascitic disease are of an unexpected nature, the most common among them are presented below. It:
- malignant neoplasms and metastases,
- cirrhosis and increase in blood pressure in the portal system,
- thrombosis (narrowing of the hepatic, inferior vena cava and portal vein),
- acute and chronic inflammatory diseases of the kidneys,
- nephrotic cider (with the urine begins to output protein),
- chronic renal failure
- inflammatory damage to the serous membrane of the heart,
- acute and chronic heart failure
- some infectious and inflammatory bowel diseases that cause diarrhea and protein loss,
- inflammation of the pancreas,
- pseudomyxoma (accumulation of mucus),
This disease is a complication of cirrhosis of the liver and not only. In the body progresses gradually, the first time does not manifest itself. Ascites of the abdominal cavity is difficult to treat successfully. However, healing occurs if the main pathogenic factor is eliminated.
The main drugs that help remove excess fluid from the body are diuretics. Thanks to their reception, it is possible to achieve the transfer of excess fluid from the abdominal cavity into the blood stream, which helps reduce the symptoms of ascites.
- To begin, patients are prescribed the smallest dose of diuretics to minimize the risk of side effects. An important principle of diuretic treatment is the slow increase in diuresis, which will not lead to significant losses of potassium and other major metabolites. Most often they recommend taking the drugs Aldactone, Veroshpiron, Triamteren, Amiloride. In parallel, prescribe potassium drugs. At the same time, hepatoprotectors are introduced into the treatment regimen.
- At the same time, doctors carry out daily monitoring of the patient’s diuresis and, if treatment is ineffective, increase the dose of the drugs or replace them with stronger drugs, for example, Triampur or Dichlothiazide.
In addition to diuretic drugs, patients are prescribed funds aimed at strengthening the walls of blood vessels (vitamin C, vitamin P, Diosmin), drugs that prevent the outflow of fluid outside the vascular bed (Reopoliglyukin). Improves the exchange of liver cells the introduction of protein preparations. Most often, concentrated plasma or albumin solution in a 20% concentration is used for this purpose.
Antibacterial drugs prescribed in the event that ascites has a bacterial nature.
Laparocentesis of the abdominal cavity
In ascites, laparocentesis of the abdominal cavity is a surgical procedure in which fluid is removed from the abdominal cavity by puncture. At one time should not be pumped out more than 4 liters of exudate, as it threatens the development of collapse.
The more often the puncture is performed for ascites, the higher is the risk of peritoneal inflammation. In addition, the likelihood of the formation of adhesions and complications from the procedure being conducted increases. Therefore, with massive ascites, it is preferable to install a catheter.
Indications for laparocentesis is intense and refractory ascites. The liquid can be pumped out with the help of a catheter, or it simply flows freely into the prepared dishes, after the trocar is inserted into the abdominal cavity.
Peritoneovenous shunting (Levin's shunt)
Sometimes used to treat refractory ascites i. one that is not amenable to drug therapy and returns quickly after puncture. The operation is to increase the volume of circulating blood by the constant flow of fluid from the abdominal cavity into the general blood flow system.
Levin's shunt is a long plastic tube that fits into the abdominal cavity, reaching the pelvic floor. Next, the shunt is connected to the valve and a silicone tube, which passes subcutaneously to the neck area for subsequent connection with the internal jugular and superior vena cava. The valve opens by means of the generated force of the displacement of the diaphragm and an increase in intra-abdominal pressure. Thus, there is an unobstructed flow of fluid into the superior vena cava.
It provides for a reduction in fluid intake, as well as salt due to the fact that it retains fluid in the body. Doctors advise Avicenna diet. Such a diet for ascites provides for an almost complete rejection of fatty foods, eating nuts in large quantities, the rejection of fresh fruits in favor of dry ones.
Also liquid food (borscht, soup) should be replaced with broth with additives in the form of celery, parsley, fennel. The ascites diet does not regulate how much meat the patient should eat, but all meat should be lean (chicken, turkey, rabbit).
How many people live with ascites?
The life expectancy of people with diagnosed ascites varies widely, depending on a number of factors. The life expectancy of a patient with ascites is due to:
- The time to start treatment. If ascites is detected at early stages of development, when the functions of vital organs are not impaired (or only slightly impaired), the elimination of the underlying disease can lead to the complete cure of the patient. At the same time, with long-term progressive ascites, damage to many organs and systems (respiratory, cardiovascular, excretory) can occur, leading to the death of the patient.
- Severity of ascites. Transient (mild) ascites does not pose an immediate threat to the patient’s life, while intense ascites, accompanied by the accumulation of tens of liters of fluid in the abdominal cavity, can lead to acute heart or respiratory failure and death of the patient within hours or days.
- The main disease. This is perhaps the main factor determining the survival of patients with ascites. The fact is that even with the most modern treatment, a favorable outcome is unlikely if the patient has a failure of several organs at once. For example, with decompensated liver cirrhosis (when the organ’s function is almost completely impaired), the patient’s chances of survival for 5 years after the diagnosis is less than 20%, and for decompensated heart failure, less than 10%. A more favorable prognosis for chronic renal failure, as patients who are on hemodialysis and who comply with all doctor's prescriptions, can live for decades or more.
The presence of ascites significantly aggravates the course of the underlying disease and worsens its prognosis. Complications of ascites itself can be spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, bleeding.
In the case of the failure of conservative treatment, the patient is prescribed a procedure of laparocentosis, which consists in removing fluid from the peritoneum by puncturing its wall and using a special apparatus for sucking water. This procedure is performed under local anesthesia.
The maximum amount of fluid that can be removed during laparocentosis is 5 liters. The procedure is repeated after 3-4 days. It should be noted that each subsequent procedure is an increasing danger to the patient, which is the possibility of damage to the intestinal walls.
Therefore, re-spend it infrequently. In case the fluid fills the abdominal cavity too quickly, the patient is placed on a peritoneal catheter to prevent the appearance of adhesions possible with ascites.
Prevention of ascites is the prevention of diseases that cause it. That is, it is necessary to treat infectious diseases in a timely manner, not to abuse alcohol, to exercise moderately and to eat right. If you have problems with your heart, kidneys or liver, you should regularly undergo examination by specialists and carefully follow their instructions.
Questions and answers on "Ascites"
Question:Hello. After an ultrasound examination of the liver and gallbladder, I was told that there was fluid in the abdominal cavity. The skin has a yellowish color. Question: Is it possible to drink a diuretic? The liver is slightly enlarged, bile, too, but without stones. Thank.
Answer: Hello. Diuretic with ascites helps to significantly alleviate the condition of the patient, but they are not able to completely eliminate the fluid in the stomach. And all because the described complication is secondary, without addressing the root cause, it is impossible to defeat the dropsy of the abdomen. Fluid will constantly accumulate in the peritoneum, and provoke worsening of the overall symptoms. Any diuretic drugs for ascites can also be prescribed at the stage of diagnosis, wanting to ease the patient's well-being, and be part of a comprehensive combination therapy for the disease that became the root cause of the development of a dangerous complication.
Question:Good day. My spouse is 32 years old, I was diagnosed with gastric adenocarcinoma T4N2M2. A trial laparoscopy was performed. From the operation protocol: during revision: the stomach is totally affected by an infiltrative tumor, serous cover grows, extends to the abdominal esophagus up to the level of the diaphragm. The esophagus in the tumor conglomerate is not differentiated. dense increased to 1.5-2 cm l paracardial, in the abdominal space, in the left gastric artery conglomerate of dense l y to 2.5 cm. The tumor grows into the abdominal space, pancreas, spleen gates. On the parietal peritoneum, multiple whitish knots of 0.3-1.0 cm. To date, the husband has not been removed by stitches and ascites has begun - he complains of abdominal pain, bloating, which keeps him awake at night. The spouse has general weakness, excessive sweating and nausea. Tell me, how can you get rid of ascites? Doctors except diuretics do not prescribe anything, but there are no results, the pain is only getting worse. Does ascites not depend on the amount of fluid consumed?
Answer: Hello. You should contact the surgeon to decide on the possibility of laparocentesis and a chemotherapist to decide on the possibility of using chemotherapy.
Question:Good day. What specialist to contact to remove fluid from the abdominal cavity?
Answer: Hello. To the attending physician, who observes the patient for the underlying disease (which caused ascites). Removal of fluid from the abdominal cavity can be carried out both surgically (then to the surgeon), and other means (depending on the evidence).
Question:Good day. My mother is 68 years old. She is diagnosed with coronary artery disease, atrial fibrillation, type 2 diabetes mellitus, cardiac cirrhosis and gout. She has ascites. Very big belly. Severe pain and swelling of the legs. Walks with difficulty. Takes furosemide 3 tablets 40mg + 0.5 tablets 100mg of hypoteasite and asparkam. But the swelling does not pass. Please tell me which doctor is best for her specialty?
Answer: Hello. The cause of ascites can be both heart problems and a number of other causes. It is better to understand the conditions of the hospital. This may be a general therapeutic department, may be cardiology.
Question:Good day. Two years ago, my mother underwent surgery to resect 4/5 of the stomach (cancer), after surgery, chemotherapy was not prescribed, in October 2012. mom had a temperature of 38-39, which did not subside during the month, were examined, the ultrasound showed a large accumulation of free fluid in the abdominal cavity, the doctors prescribed two chemotherapy sessions, but the accumulation of fluid increases every day. Can I get rid of ascites without chemotherapy?
Answer: Hello, with the accumulation of a large amount of fluid, it is removed mechanically, the procedure is called laparocentesis, and chemotherapy has a therapeutic effect, inhibits further progression in the form of fluid accumulation, but, unfortunately, it is not always effective.
Ascites of the abdominal cavity in oncology, prognosis
In cancer, malignant cells multiply uncontrollably. If, during metastasis, they enter the liver, then it causes squeezing of its sinusoids (spaces between groups of cells filled with blood) and an increase in pressure in the portal vein and the vessels nearest to it.
As a result, the outflow of blood and lymph from the peritoneum slows down and there is ascites of the abdominal cavity in oncology. How many live in this state? Only half of the dropsy patients who received her timely therapy remain alive for two years. High mortality due to the rapid development of complications of edema, including:
- respiratory failure
- intestinal obstruction
- formation and pinching of umbilical hernia,
- hepatorenal syndrome,
- prolapse of the rectum.
More often the other cancers cause ascites:
- pancreatic tumor
- ovarian cancer
- abdominal carcinomatosis,
- Meigs syndrome.
The prognosis in the development of oncological ascites worsens in old age, with a significant number of metastases and renal failure.
What is the forecast?
The prognosis of ascites directly depends on the cause of fluid accumulation and the timeliness and effectiveness of treatment. In half of the cases, in the absence of the effect of diuretics, death occurs. Adverse factors also include:
- old age - 60 years or more,
- liver cancer,
- bacterial peritonitis,
- the level of albumin in the blood is less than 30 g / l,
- decrease in glomerular filtration of the kidneys.
The danger of ascites is also that, being a symptom, a consequence of the underlying disease, it, in turn, aggravates its course.
Causes of fluid accumulation in the abdominal cavity
Often there is ascites of the abdominal cavity in oncology and many other diseases when the barrier and secretory function of the peritoneum is impaired. This leads to the filling of the entire free space of the abdomen with liquid. Constantly increasing exudate can go up to 25 liters. As already mentioned, the main cause of damage to the abdominal cavity is its close contact with the organs in which the malignant tumor is formed.The tight adherence of the folds of the peritoneum to each other provides a quick capture of nearby tissues by cancer cells.
The main causes of abdominal ascites:
- peritoneal mesothelioma,
- peritoneal carcinoma,
- cancer of internal organs
- portal hypertension
- cirrhosis of the liver,
- hepatic vein thrombosis,
- venous congestion with right ventricular failure,
- heart failure,
- gastrointestinal tract diseases
- skidding of atypical cells in the peritoneum.
Fluid inside the abdominal cavity in the female population is not always a pathological process. It can be collected during ejaculation, which occurs monthly in women of reproductive age. Such liquid resolves independently, without representing health hazard. In addition, the cause of water often become purely female diseases that require immediate treatment - inflammation of the reproductive system or ectopic pregnancy.
The development of ascites is caused by intra-abdominal tumors or internal bleeding, for example, after surgery, due to injury or cesarean section. When the endometrium lining the uterus, expands uncontrollably, because of what goes beyond the limits of the female organ, water also collects in the peritoneum. Endometriosis often develops after suffering viral or fungal infections of the reproductive system.
In all cases, the occurrence of dropsy in the representatives of the stronger sex is the basis of a combination of violations of important functions of the body, which lead to the accumulation of exudate. Men often abuse alcohol, which leads to cirrhosis of the liver, and this disease provokes ascites. Other factors such as blood transfusions, injections of narcotic drugs, high cholesterol levels due to obesity, and multiple tattooing on the body also contribute to the occurrence of the disease. In addition, the following pathologies cause men with dropsy:
- tubercular peritoneal damage,
- endocrine disorders
- rheumatoid arthritis, rheumatism,
- lupus erythematosus,
Liquid in the stomach is collected not only in adults but also in children. Most often, ascites in newborns arises from infectious processes occurring in the mother's body. As a rule, the disease develops in the womb. The fetus may experience defects in the liver and / or biliary tract. Because of this, bile stagnates, leading to dropsy. After birth in an infant, ascites may develop in the background:
- cardiovascular disorders
- nephrotic syndrome,
- chromosomal abnormalities (Down's disease, Patau, Edwards or Turner syndrome),
- viral infections
- hematological problems
- congenital tumors
- severe metabolic disorders.
Signs of abdominal ascites depend on how quickly the ascites fluid collects. Symptoms may appear on the same day or for several months. The most obvious sign of dropsy is an increase in the abdominal cavity. This causes an increase in body weight and the need for larger clothing. In a patient with an upright position, the abdomen hangs down like an apron, and when horizontal, it is spread over two sides. With a large amount of exudate, the navel bulges out.
If portal hypertension is the cause of dropsy, a venous pattern is formed on the anterior peritoneum. It occurs as a result of varicose paraumbilical veins and varices of the esophagus. With a large accumulation of water in the abdomen, the internal pressure increases, as a result of which the diaphragm moves into the abdominal cavity, and this provokes respiratory failure. The patient has pronounced shortness of breath, tachycardia, cyanosis of the skin. There are common symptoms of ascites:
- pain or feeling of tearing in the lower abdomen,
- peripheral swelling of the face and limbs,
- loss of appetite,
- slow motion.
In clinical practice, there are 3 stages of abdominal dropsy, each of which has its own characteristics and features. The degree of development of ascites:
- Transient. The initial development of the disease, the symptoms of which are impossible to notice on their own. The volume of liquid does not exceed 400 ml. Excess water is detected only during instrumental examinations (ultrasound examination of the abdominal cavity or MRI). With such volumes of exudate, the work of the internal organs is not disturbed, so the patient does not notice any pathological symptoms. At the initial stage, dropsy is successfully treatable if the patient observes the water-salt regimen and adheres to a specially prescribed diet.
- Moderate. At this stage, the stomach becomes larger, and the volume of fluid reaches 4 liters. The patient has already noticed anxious symptoms: the weight increases, it becomes difficult to breathe, especially in the supine position. The doctor easily determines the dropsy during the examination and palpation of the abdominal cavity. Pathology and at this stage is well treatable. Sometimes it is necessary to remove fluid from the abdominal cavity (puncture). If an effective therapy is not carried out in time, then a malfunction of the kidneys occurs, the most severe stage of the disease develops.
- Tense. Fluid volumes exceed 10 liters. In the abdominal cavity, the pressure is greatly increased, there are problems with the functioning of all the organs of the gastrointestinal tract. The patient's condition worsens, he needs immediate medical assistance. The previous therapy does not give the desired result. At this stage, laparocentesis is necessarily performed (puncture of the abdominal wall) as part of complex therapy. If the procedure has no effect, refractory ascites develops, which is no longer treatable.
When ascites progresses and the treatment does not help, in particularly advanced cases surgical treatment is prescribed. Unfortunately, not always, even with the help of an operation, it is possible to save the patient's life, but there are no other methods today. The most common surgical treatment:
- Laparocentesis. There is a removal of exudate through a puncture of the abdominal cavity under the control of ultrasound. After surgery, drainage is established. In one procedure no more than 10 liters of water is removed. In parallel, the patient is administered drip saline and albumin. Complications are very rare. Sometimes infectious processes occur at the puncture site. The procedure is not carried out in case of bleeding disorders, severe abdominal distension, intestinal injuries, wind hernia and pregnancy.
- Transjugular intrahepatic shunting. During the operation, the hepatic and portal veins are artificially communicated. The patient may have complications in the form of intra-abdominal bleeding, sepsis, arteriovenous shunting, liver infarction. Do not prescribe an operation if the patient has intrahepatic tumors or cysts, vascular occlusion, obstruction of the bile ducts, cardiopulmonary pathology.
- Liver transplantation. If ascites develops in the presence of cirrhosis of the liver, an organ transplant may be prescribed. Few patients have a chance for such an operation, since it is difficult to find a donor. The absolute contraindications to transplantation are chronic infectious diseases, severe disruption of other organs, and cancer. Among the most severe complications is graft rejection.
Adherence to the main disease of ascites significantly worsens its course and worsens the prognosis for recovery. Especially unfavorable is the pathology for older patients (after 60 years), who have a history of renal failure, hypotension, diabetes mellitus, heptocellular carcinoma, hepatocellular insufficiency or cirrhosis of the liver. Two-year survival of such patients is not more than 50%.