In the article, we will consider the causes of abdominal ascites.
It is a secondary condition that 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 pathology includes CT, ultrasound, diagnostic laparoscopy, ultrasound with analysis of ascitic fluid. To start pathogenetic therapy of ascites, in any case, it is necessary to determine the cause that caused the accumulation of fluid. In case of ascites, symptomatic measures are the appointment of diuretics to the patient, as well as the puncture elimination of fluid from the peritoneal cavity.
Ascites
Swelling of the abdomen, also known as abdominal dropsy or ascites, can accompany the course of the most extensive list of diseases in the field of gynecology, lymphology, gastroenterology, rheumatology, cardiology, oncology, endocrinology, urology. Accumulation of peritoneal fluid in this pathologycharacterized by an increase in pressure inside the peritoneum, pushing the diaphragmatic dome into the chest cavity. At the same time, respiratory pulmonary excursion is severely limited, blood circulation, the activity of the heart and peritoneal organs are disturbed. Massive abdominal edema may also be accompanied by electrolyte defects and significant protein loss. With ascites, thus, heart and respiratory failure, severe metabolic disorders can develop, due to which the prognosis of the main disease worsens.
Causes of abdominal ascites
The serous cover of the peritoneal cavity is normal - this is the production of a small amount of fluid by the peritoneum, which is required for the free movement of intestinal loops and the prevention of possible gluing of organs. This exudate is reabsorbed by the same peritoneum. Due to a number of diseases, the barrier, resorptive and secretory functions of the peritoneum are disrupted, which causes ascites.
More often there is swelling of the abdomen in men with cirrhosis.
In ascitic syndrome, the abdomen is usually enlarged evenly, the skin is stretched. In many patients, blue patterns can be seen on the abdominal wall that resemble the head of a jellyfish. Their occurrence provokes portal hypertension and, as a result, the expansion of venous vessels. As intra-abdominal pressure increases, the navel protrudes outwards. Over time, in patients who suffer from ascites, a hernia of the umbilical ring is detected. Swelling of the abdomen with cirrhosis of the liver occurs in the last stages of the pathology.
Uneonatal ascites is often observed in hemolytic disease of the fetus. At an early age - with exudative enteropathy, malnutrition, congenital nephrotic syndrome. Ascites can develop with various abdominal disorders:
- diffuse peritonitis of tuberculous, parasitic, fungal, non-specific etiology;
- pseudomyxoma;
- abdominal mesothelioma;
- peritoneal carcinosis due to cancer of the stomach and colon, 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 in systemic lupus erythematosus, rheumatism, uremia, rheumatoid arthritis, Meigs syndrome (including with the inclusion of hydrothorax, ascites and ovarian fibromas).
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 may 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; congestion of veins in right ventricular failure.
Protein deficiency
Ascites can develop due to protein deficiency, kidney disease (chronic glomerulonephritis, nephrotic syndrome), myxedema, heart failure, lymphostasis due to compressionlymphatic duct of the sternum, obstruction of lymph outflow from the peritoneal cavity, lymphangiectasias, gastrointestinal diseases (Crohn's disease, pancreatitis, chronic 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 complex of hemodynamic, inflammatory, water-electrolyte, hydrostatic and metabolic defects, as a result of which interstitial fluid is shed and accumulates in the peritoneal cavity.
Ascites symptoms
Swelling of the abdomen, depending on the causes, may develop gradually, when it increases over several months, or suddenly. The patient usually notices weight gain, changes in clothing size, or difficulty fastening the belt.
Clinical symptoms of ascites are distinguished by a feeling of fullness in the abdomen, abdominal pain, heaviness, flatulence, belching and heartburn, nausea. The abdomen, as the volume of fluid increases, increases in size, the navel protrudes. In a standing position - the stomach is sagging, in the prone position - flattened, swells in the lateral sections (the so-called "frog belly"). If the peritoneal effusion is large, there are swelling in the legs, shortness of breath, difficulty in movement, especially bending and turning the torso. A strong increase in pressure inside the peritoneum with ascites can lead to femoral or umbilical hernia, hemorrhoids, varicocele and rectal prolapse.
Tuberculosis peritonitis
Whentuberculous peritonitis, ascites is caused by secondary infection of the peritoneal cavity due to intestinal or genital tuberculosis. Tuberculous ascites is also characterized by fever, weight loss, symptoms of general intoxication. In addition to ascitic fluid, lymph nodes along the intestinal mesentery are diagnosed in the peritoneal cavity. The exudate, which was obtained from tuberculous ascites, has a density of more than 1016, and the protein content is from 40 to 60 g/l, the sediment, including endothelial cells, erythrocytes and lymphocytes, contains tuberculous mycobacteria, a positive Riv alt test.
Swelling of the abdomen with cancer is very common. If ascites accompanies peritoneal carcinosis, it is distinguished by many enlarged lymph nodes that are palpable through the anterior wall of the peritoneum. The main complaints in 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 (in some cases, malignant ovarian tumors), hydrothorax and ascites are determined. Characterized by severe shortness of breath and abdominal pain. Right ventricular failure of the heart, proceeding along with ascites, is expressed by edema 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 on the background of portal vein thrombosis has a stubborn character,and is also accompanied by a clear pain syndrome, mild hepatomegaly, splenomegaly. Due to the occurrence of collateral circulation, extensive bleeding from hemorrhoids or varicose esophageal veins often appears. Thrombocytopenia, leukopenia, anemia are determined in the peripheral blood.
Ascites is an ailment that accompanies portal intrahepatic hypertension, characterized by moderate hepatomegaly, muscular 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 swelling of the abdomen with heart failure. In sedentary patients with heart disease, there is an accumulation of fluid in the abdomen, sacrum, sides, and pelvic organs. Puffiness, although considered the most characteristic sign of heart failure, is not the only one. Patients have shortness of breath and tachycardia, which indicates the neglect of the pathology.
With protein deficiency, ascites is most often minor; pleural effusion, peripheral edema are noted. In rheumatic diseases, polyserositis is expressed by specific symptoms of the skin, the presence of fluid in the cavity of the pleura and pericardium, ascites, arthralgia and glomerulopathy. With violations of the outflow of lymph (chylous ascites), the size of the abdomen rapidly increases. Ascitic fluid of a milky hue, pasty consistency, in it in the laboratorythe study determined lipoids and fats. The volume of fluid in the peritoneal cavity with ascites can reach up to 5-10 or even 20 liters.
Swelling of the stomach 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 - an ovarian cyst, obesity, tumors of the peritoneal cavity, pregnancy, etc. To diagnose the pathology and its source, palpation and percussion of the abdomen, MSCT of the peritoneum, ultrasound of the lymphatic and venous vessels, ultrasound of the peritoneal cavity, liver scintigraphy, examination of ascitic fluid, diagnostic laparoscopy are performed.
How to determine the swelling of the abdomen, it is interesting to many.
With ascites, percussion of the abdomen is characterized by dullness of the sound, as well as a shift in the border of dullness during a change in body position. If you put your palm on the side of the abdomen, you can feel tremors (a sign of fluctuation) when you tap your fingers on the opposite surface of the abdomen. Plain radiography of the peritoneal cavity can identify ascites if the amount of free fluid is more than half a liter.
With ascites from laboratory tests, analysis of the coagulogram, levels of IgG, IgM, IgA, biochemical liver tests, the degree of general urine analysis are carried out. In patients with portal hypertension, EGDS is prescribed to detect altered varicose veins of the stomach or esophagus. Fluid in the pleural cavities, a high state of the diaphragmatic fundus, and limitation of pulmonary respiratory excursion can be determined on fluoroscopy of the sternum.
BIn the process of ultrasound of the organs of the peritoneal cavity with ascites, the condition 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, the absorption-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 state of the splenoportal bed, selective angiography is performed - splenoportography (portography).
All patients with ascites, detected for the first time, undergo a diagnostic laparocentesis of sampling 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, exploratory laparotomy or laparoscopy with targeted abdominal biopsy is indicated.
Ascites treatment
In the 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, fluid restriction, a s alt-free diet, diuretics (Furosemide, Spironolactone under the cover of drugs with potassium) are prescribed, defects in water-electrolyte metabolism are corrected and portal hypertension is reduced by means of receptor antagonists of ACE inhibitors and angiotensin II. At the same time, hepatoprotectors are used, as well as intravenous administration of protein preparations (albumin solution, native plasma).
Many wonder what Furosemide is prescribed for.
It is a strong and fast-acting diuretic (diuretic). It should be taken in the minimum dosage, which will give the desired effect. Furosemide is prescribed, usually for edema associated with:
- heart disease;
- congestion in the systemic and pulmonary circulation;
- hypertensive crisis;
- disorders of the kidneys (nephrotic syndrome);
- liver disease.
Medication should be monitored by a physician due to possible side effects and the risk of overdose leading to dehydration, heart failure, dangerous low blood pressure and other dangerous effects.
Why "Furosemide" is prescribed to patients is now clear.
With ascites, which is resistant to ongoing drug treatment, abdominal laparocentesis (paracentesis) is used, that is, puncture removal of fluid from the peritoneal cavity. For one puncture, it is desirable to evacuate no more than four to six liters of ascitic fluid due to the possibility of collapse. If the punctures are often repeated, conditions are created for abdominal inflammation, the formation of adhesions, and the likelihood of complications from further laparocentesis sessions increases. That is why with prolonged removal of fluid with massive ascites, a permanent peritoneal catheter is installed.
Interventions that provide conditions for directremoval of peritoneal fluid are partial deperitonization and peritoneovenous shunt of the walls of the peritoneal cavity. With ascites, indirect interventions are operations that reduce pressure in the portal system. These include manipulations with the imposition of various kinds of porto-caval anastomoses (intrahepatic transjugular portosystemic shunting, porto-caval shunting, 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 their content is not affected by diuretics. Decreased levels of opsonins may increase the risk of primary peritonitis
The problem of the expediency of introducing colloidal solutions to the patient after the elimination of a large volume of ascitic fluid has not yet been solved. The cost of one albumin infusion ranges from $120-1250. Changes in serum creatinine, electrolytes, and plasma renin in patients who have not received colloid infusion do not appear to be of clinical significance and do not result in increased morbidity or mortality.
Bypassing. Approximately five percent of 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-to-side portoqual shunting is performed, but itcharacterized by high mortality. Denver or peritoneovenous shunting, for example, according to Le Vin, can improve the condition of some patients. In most cases, a person still needs to take diuretics, but their dosages can be reduced. Among other things, the blood flow of the kidneys improves. Thirty percent of patients develop shunt thrombosis and need to be replaced. Peritoneovenous shunting is contraindicated in heart failure, sepsis, bleeding from varicose veins, and a history of malignancy. Patient survival and complication rates in people with cirrhosis following this form of bypass surgery is determined by the degree to which kidney and liver function are impaired. The best results were obtained in patients with persistent ascites, but at the same time, fairly intact liver function. Currently, peritoneo-ovenous bypass surgery is reserved for only a few patients who fail neither laparocentesis nor diuretics, or who fail diuretics in people who travel too long to see a specialist to undergo biweekly therapeutic laparocentesis
Orthopedic liver transplantation can also be done for stubborn ascites if there are other indications for it.
Prognosis for pathology
The presence of swelling of the abdomen significantly aggravates the course of the underlying disease and worsens the prognosis. Ascites itself can develop complications such as spontaneous bacterial peritonitis, hepatorenalsyndrome, hepatic encephalopathy and bleeding.
Unfavorable 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. For ascites, the two-year survival rate is about fifty percent.
Probability of recurrence and possible complications
It must be remembered that because of 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 he alth, since there is always a chance of relapse. That is why even after getting rid of ascites, it is necessary to adhere to a diet prescribed by a specialist.
If a person wonders why the stomach has become big, he needs to juicy go to the doctor.
The accumulation of fluid in the peritoneal cavity can cause severe discomfort, but before this happens, other signs appear. They should not be left unattended, you should definitely consult a doctor.
