Ascites in liver cirrhosis

Ascites or the popular "dropsy" is not a separate disease. The accumulation of effusion in the peritoneal cavity with the subsequent increase in the abdomen is one of the manifestations of decompensation of the adaptive mechanisms of the human body.

In clinical course of various diseases ascites is considered as a natural symptom and consequence of disorders or a serious complication. Ascites in liver cirrhosis occurs in 50% of patients for 10 years, and among the causes of this disease is ¾ of all cases of dropsy.

Since most cases of liver cirrhosis are associated with alcoholism and affect men( 75-80%), then ascites is more often observed in the stronger sex.

It is almost impossible to cure ascites, since there are no radically active drugs that will restore the cirrhosis-disturbed metabolism. A sick person has to struggle with the excess of fluid formation until the end of life.

What are the disorders of cirrhosis of the liver causing ascites?

In the pathogenesis of ascites against a cirrhosis of the liver, for a long time the main role was given to two types of changes:

• in the growth of pressure in the portal vein( portal hypertension), which spreads to the entire regional venous and lymphatic network;
• sharply reduced liver function by protein synthesis due to the replacement of some cells with fibrous tissue.

As a result, the necessary conditions for the exit of the liquid part of the blood and plasma appear in the vessels of the abdominal cavity:

• , the hydrostatic pressure that significantly presses the liquid outwardly increases;
• decreases oncotic pressure, which is mainly maintained by the albumin fraction of proteins( by 80%).

In the abdominal cavity a small amount of liquid is constantly present to prevent the gluing of the internal organs, the sliding of the intestine. It is renewed, the excess is absorbed by the epithelium. With the formation of ascites, this process stops. The peritoneum is not able to absorb a large volume.

The severity of ascites completely depends on the degree of loss of hepatocytes. If, with hepatitis( inflammation), you can hope to remove the process and complete recovery of functions, then the areas of cirrhotic scar tissue can not later turn into hepatic cells. Medical measures only support the remaining stock of hepatocytes and compensate for lost functions. Without a constant treatment, the patient can not live.

Additional causes appear in response to a decrease in the volume of circulating blood:

• connects the mechanism for compensating oxygen starvation of tissues( release of antidiuretic hormone and aldosterone), which contribute to sodium retention, according to the laws of chemistry to its moleculeswater is added;
• gradually increases the hypoxia of the heart muscle( myocardium), the force of the discharge of blood decreases, which leads to stagnation in the inferior vena cava, edema on the legs due to delay of blood on the periphery.

Modern view on the development of ascites

Portal scientists believe that portal hypertension, hemodynamic disorders and neurohormonal regulation are considered start factors in the development of ascites. Pathogenetic disorders are considered as a combination of different levels of the progressive process. All the above reasons are classified as systemic or general. But more importance is attached to local factors.

These include:

• increased vascular resistance within the hepatic lobules, they can be reversible and irreversible( complete block);
• intrahepatic block promotes strengthening of lymphatic formation, it seeps through the vascular wall and capsule of the liver directly into the abdominal cavity or "floods" the portal vein and thoracic lymphatic duct;
• accumulation in the blood of patients of unsplit substances with vasodilator action( vasodilators such as glucagon) that lead to the expansion of peripheral arteries, open arteriovenous shunts in organs and tissues, and as a result, blood filling of arteries decreases, cardiac output increases, portal hypertension also increases;
• reflexively stores a significant part of the plasma in the vessels of the abdominal cavity;
• action of vasodilators is enhanced when liver nitric oxide is inadequate.

It is from the sinusoids that fluid enters the veins and lymphatic vessels. Increased pressure inside the lobules leads to its penetration into the near-sinusoidal space, and then into the peritoneum.

Symptoms of the disease

Since we describe the patient's condition in ascites caused by cirrhosis of the liver, all the symptoms should be divided into cirrhosis-dependent or determining ascites. In medical terminology the general name "edematous-ascitic syndrome" is used, which includes all disorders in cirrhosis.

Symptoms of cirrhosis include dull pain in the hypochondrium on the right or a feeling of heaviness after eating, especially greasy and spicy food, drinking alcohol, physical work, constant bitterness or unpleasant aftertaste in the mouth, nausea, rare vomiting.

There are complaints of weakness, bloating and rumbling in the abdomen, quickened loose stools, sudden weight loss. The patient suffers from itching of the skin, pallor, a yellowish shade of dry skin. Impotence and growth of mammary glands in men, as well as a violation of menstrual function and the ability to become pregnant in women - possible complications of pathology.

Experts diagnose a change in the state of the language. It is called "lacquered" due to redness and swelling. Vascular asterisks appear that form on the face( in the area of ​​the nose, eyelids) can bleed, a periodic increase in temperature.

Appearance of bruises due to blood clotting disorder, changes in urine( becomes dark and cloudy), and feces lightens - concomitant changes. Upon examination, the doctor discovers an enlarged painful liver.

Direct symptomatology of ascites arises against the background of already existing manifestations of cirrhosis, when the volume of accumulated liquid exceeds a liter. For a few days the patient notices a significant increase in the abdomen. The skin becomes stretched, smooth, with striae( white stripes) on the sides, the navel protrudes outwards. Expanded veins are woven into the net around the navel, forming a picture of the "jellyfish head".

Characteristic change in the shape of the abdomen in a different position of the patient: standing standing roundness, hanging down, lying on his back - the stomach spreads out to the sides, becomes like a frog. Patients have pain closer to the sternum( stagnation in the left lobe of the liver).

Pressure on the dome of the diaphragm leads to a decrease in pulmonary space. The patient has dyspnea, which is worse when lying down. It becomes impossible to sleep without a high headrest or pillow. Simultaneous stagnation in the lungs is manifested by coughing with phlegm, cyanosis of the lips.

Constant pressure on the stomach is accompanied by a feeling of heaviness, even with a small amount of food, heartburn, belching. Less often there is vomiting of food, bile, intestinal contents.

Disturbance of the stool is manifested by diarrhea and prolonged constipation with a clinic of intestinal obstruction. The patient notes dysuric phenomena: frequent urination, painful urge. Inflammatory diseases of the kidneys, bladder. On the feet and legs, edema is formed due to the addition of heart decompensation, stagnation of lymph.

If the accumulation of ascites fluid reaches 15-20 liters, the patient will have:

• hernia of the white line, inguinal or umbilical;
• enlargement of hemorrhoidal veins with exacerbation of hemorrhoids, bleeding;
• visible swelling of veins on the neck due to increased pressure in the jugular vein;
• in 6-7% of patients an additional effusion to the right pleural cavity( hydrothorax) is formed.

In addition to the enlarged and dense liver, when viewed, the doctor conducts a fluctuation test: pushing the abdomen from one side, the other hand senses the coming wave. Percussion in places of maximum fluid accumulation determines stupidity. It changes when the patient turns to the other side.

Ascites

Severe illness has a sobering effect on a person drinking. He begins to worry about the question of whether the disease can be cured. Unfortunately, while there is a real possibility only to slow down the course of irreversible phenomena, if ascites and cirrhosis are detected at an early stage.

The first or the initial stage - the patient does not accumulate more than 3 liters of fluid, the stomach is enlarged slightly, characterized by a favorable prognosis, patients live longer than other patients when the doctor's recommendations are followed.

The second - is formed when there are 4-10 liters of fluid in the abdominal cavity, all clinical manifestations are pronounced, it is possible to attach renal failure.

Third - the volume of the abdomen reaches a large size, the amount of fluid in the peritoneum is more than 10 liters. The patient's condition deteriorates rapidly. There are signs of shortness of breath, cardiac decompensation. Swelling spreads throughout the body.

Diagnostic value of ascites

When examined, the doctor can detect only more than 1.5 liters of fluid by percussion of the abdomen with the patient turning from side to side and jogging. In differential diagnosis, it is taken into account that adherent peritonitis in tuberculosis and ovarian cyst is more often of a characterized character and does not give a change in sound during percussion.

fluid. If the diagnosis remains unclear, then a diagnostic laparocentesis with complete cytological and biochemical examination of the fluid is indicated. The fence is from 50 to 200 ml. More accurate indications for the procedure:

• ascites, first detected;
• differential diagnosis of cirrhosis with malignant tumor;
• need to exclude bacterial peritonitis.

When analyzed in ascites, the following are determined:

• total protein and fractions;
• glucose;
• cholesterol and triglycerides;
• bilirubin;
• activity of amylase;
• leukocyte reaction and erythrocytes;
• atypical cells.

Make a culture on the microflora, determine the sensitivity to antibiotics. It is recommended to count the serum-ascitic albumin gradient, which is equal to the difference between the level of albumin in the blood serum of the patient and in the liquid. The index of 1.1 indicates portal hypertension.

How to treat ascites with cirrhosis?

Treatment of ascites with liver cirrhosis is necessarily combined with therapy for the primary lesion. Therefore, the basic therapy and diuretic is allocated. The basic treatment includes all ways to support functional liver failure, compensate for a reduced level of proteins, balance electrolytes.

The patient is recommended bed rest, because it is known that in the horizontal position the influence of the sympathetic nervous system decreases, the production of angiotensin and renin, improves the filtration processes in the renal tubules.

To support the remaining hepatocytes,

• -hepatoprotectants are used( Carcil, ursodeoxycholic acid, Phosphogliv, Essentiale);
• choleretic( Allochol);
• amino acids( Ornithine and Methionine).

In consultation with the doctor, the course application of antiviral agents( Pegasys, Ribaverin, Adefovir), anti-inflammatory steroids, and albumin solution are dripped. Therapy with diuretics is carried out by a combination of two groups of drugs:

• loop diuretics( Furosemide, ethacrynic acid, Bumetanide);
• Spironolactone, Triamterene.

This combination allows you to keep potassium in the blood, as much as possible to withdraw sodium and water.

To monitor the amount of ascites fluid, the patient is weighed daily. Admissible weight loss is:

• in cases of ascites with edema - no more than 1 kg;
• if ascites is not accompanied by edema - 0.5 kg.

After elimination of ascites, maintenance doses are prescribed. If there is no reaction to the therapy, they talk about refractory ascites( stable).Then the treatment uses a laparocentesis with the removal of fluid through the drainage. Once it is permissible to withdraw from 4 to 10 liters in the control of hemodynamics( possibly a drop in pressure, fainting).

Such patients are shown a bypass operation to eliminate hypertension in the portal vein. In this case, the underlying pathology is not eliminated and there is no guarantee for a long-term improvement. Liver transplantation can solve all the problems.

Treatment by any folk remedies in conditions of severe fluid restrictions is impossible and useless. Recommendations for the use of diuretics should be treated with caution.

Nutrition of patients

In the diet of patients, the following rules should be observed:

• cooking without salt( individually the doctor may allow to use for salting in a dish from 0.5 to 2 g);
• a sufficient amount of protein( not less than 70 g);
• frequent fractional feeding;
• no fried, smoked, salty foods and dishes;
• categorical prohibition of alcoholic beverages;
• liquid limitation to 750-1000 ml;
• caloric content from 1500 to 2000 kcal.

Prohibited include:

• baking and sweets;
• canned food;
• fatty meat dishes;
• products with mushrooms;
• margarine and cooking fats;
• spicy seasonings, including mayonnaise;Coffee and carbonated drinks.

It is recommended to include in the daily menu:

• porridge( oat, buckwheat, rice) and cereal casseroles;
• fresh vegetables and fruits;
• sour-milk products, cottage cheese;
• low-fat fish and meat;
• rye bread;
• egg protein;
• broth of wild rose.

Complicated course of the disease

The most common severe complication of ascites is bacterial peritonitis( according to different authors it occurs in 8-32% of cases).It is caused by the tendency of the ascitic fluid to join the infection. Ends with lethal.

Less common are severe hemorrhoids with bleeding from the intestinal veins, effusion of fluid into the pleural cavity, gastroesophageal reflux, when the contents of the stomach are thrown back into the esophagus, as well as hernia of the diaphragm.

No one can give an accurate prediction how many people can survive with ascites. The course of the disease is very individual. Some authors point to the achievement of 10-year survival. Others pay attention to a five-year period without a liver transplant.

The lifestyle of the patient, the adequate response of the body to treatment plays a significant role. At half of patients within two years there are complications from which the person dies. Ascites in liver cirrhosis greatly aggravates the course of pathology. Even the fulfillment of all possible prescriptions can not stop the underlying disease.