Ascites - what is this state

Ascites is a serious complication of many diseases. It manifests itself in the enlarged abdomen due to overflow of the peritoneum with liquid. The people know the name "dropsy" more. People with such disorders can not live without diuretics.

Symptoms of ascites increase gradually, worsen the course of the underlying pathology. Increase in intra-abdominal pressure leads to difficulty in the work of internal organs, is considered in diagnosis as a stage of decompensation of the disease. In ¾ cases, the cause of ascites is cirrhosis, which led to alcoholism.

Where does the liquid come from in the abdominal cavity?

In women in the climacteric period, small edema on the face and legs is often observed, weight increases (in norm not more than 3-4 kg). These changes are associated with neuroendocrine disorders and are not related to the development of ascites.

The mechanism of pathology is formed in different ways, taking into account the pathogenesis of the main disease. Under normal conditions, the epithelium of the peritoneum releases a little liquid to prevent gluing of the internal organs, improving the slip. In composition, it approaches the blood plasma. In the human body, there are constantly processes in the abdominal cavity:

• discharge of liquid;
• reverse suction and renewal.

In ascites, venous and lymphatic vessels are involved in the process. And they, in turn, react to the changed composition of the arterial blood. The main violation - the fluid from the vessels goes through the walls into the free tissue space. For this, the balance between hydrostatic and oncotic pressure must be disturbed.

As you know, any blood pressure is provided primarily by the work of the heart muscle (myocardium). Decrease occurs in diseases that lead to a drop in the contractility of the heart (myocarditis, dystrophy, myocardial infarction). They cause circulatory failure.

Due to the violation of the mechanism of blood pumping through the right and left sections, congestion is transmitted to the entire venous network, including the veins of the abdomen (lower hollow and portal)

The increase in pressure in the venous network contributes to the dropping of the water part of the blood into the abdominal cavity. Oncotic pressure is maintained mainly by the presence of a sufficient amount of protein in the blood.

In ascites, as a rule, a mechanism is connected to the violation of protein synthesis in connection with liver diseases or stagnant phenomena. This is especially true of the albumin fraction. Reducing the concentration of protein leads to the release of fluid from the vessels.

Considerable importance is attached to the lack of oxygen in the arterial blood (hypoxic state). This is associated with a violation of cardiac output, and with the compression of the hepatic cells:

• fibrous tissue (with cirrhosis);
• expanded venules (with portal hypertension);
• neoplasm or metastasis.

The lack of oxygen causes kidney ischemia. Filtration in the glomeruli decreases. Less is excreted urine. In response, the synthesis of antidiuretic hormone in the pituitary gland and aldosterone of the adrenal glands is increased (almost 20 times). As a result, sodium is retained, and with it water.

The limiting load on the veins is transferred to the lymphatic system. From the lymph vessels the liquid passes into the peritoneum. There comes a time when the accumulation of water exceeds the capacity of the abdominal cavity by its absorption, then ascites arises.

To the mechanism of education, it is necessary to add a hormonal response to a decrease in blood mass, damage to the vascular wall in inflammatory and systemic diseases, hyperfunction of the epithelium of the abdominal cavity against a background of tumor growth and inflammation.

The causes of ascites of the abdominal cavity

The division of the causes of ascites into hepatic and extrahepatic, suggested by a number of authors, can be regarded as conditional. Because many factors are involved in the formation mechanism, as described above.

The most common reasons are:

• in 75% of cases - cirrhosis of the liver;
• in 10% - cancerous tumors or metastases;
• in 5% - the manifestation of heart failure.

The remaining 10% are:

• development of portal hypertension with thrombosis of the hepatic veins, portal vein in conditions of compression by a tumor;
• chronic kidney pathology (amyloidosis, glomerulonephritis);
• alimentary dystrophy in case of exhaustion;
• tuberculosis of the peritoneum;
• women have large cysts, oncological ovaries;
• tumors developing from peritoneal tissue (pseudomixoma, mesothelioma);
• endocrine diseases (myxedema);
• general inflammation of serous membranes in systemic diseases (rheumatism, lupus erythematosus, rheumatoid arthritis), in the stage of uremia in renal insufficiency;
• other diseases of the digestive system (pancreatitis, Crohn, sarcoidosis);
• reaction of the peritoneum to non-infectious inflammation (granitomatous and eosinophilic peritonitis).

Myxedema is a disease of the thyroid gland, which can cause ascites

Signs of ascites of the abdominal cavity can occur in children in infancy. They are associated with edema of congenital origin with rhesus-incompatibility with the mother, usually cases 100% end fatal, congenital anomalies of the liver and biliary tract, and nephrotic syndrome of an innate nature.

What factors increase the risk of ascites?

The risk group can include individuals with the highest probability of developing the main diseases that lead to ascites:

• abusing alcohol;
• smokers;
• drug addicts;
• who have experienced acute hepatitis and who suffer from chronic forms;
• after a blood transfusion;
• needing hemodialysis support for renal filtration;
• addicted to tattooing;
• having excess body weight, obesity;
• patients with diabetes mellitus;
• with signs of impaired protein and fat metabolism by blood tests;
• addicted to fashionable diet for weight loss;
• having hereditary burden on oncological pathology.

On the specific features of ascites in cirrhosis of the liver, read more in this article.

Symptoms

Ascites usually appear after accumulation in the abdominal cavity from one to one and a half liters of fluid. In acute diseases (thrombosis of the portal vein), it develops rapidly. At others - it is inclined to gradual development within several months. The greatest size reaches ascites in connection with the consequences of pathology of lymph circulation.

Another characteristic of clinical manifestations is the association with other edema and signs of fluid retention. Thus, in the pathology of the liver, ascites is not accompanied by edema on other parts of the body, and in case of heart failure, anasarka first appears (light skin swelling), edema on the feet and legs, and then fluid accumulates in the abdomen.

The patient is already at an early stage concerned about raspiranie after eating and fasting, abdominal pain due to the nature of the underlying disease, for example, with stagnation in the liver increases the left lobe, and patients complain of pain in the epigastrium. Changes in height, weight and volume of the abdomen, there is swelling of the intestine and difficulties in dressing shoes, slopes of the body.

The expansion of the venous network in the form of a "jellyfish head" is maintained after laparocentesis

In connection with the rise of the dome of the diaphragm, the patient has:

• symptoms of reflux of stomach contents into the esophagus (heartburn, belching);
• shortness of breath first only when walking, then at rest, especially when lying down;
• a person can not sleep on a low pillow;
• edema spreads in the groin, in men on the scrotum;
• it is possible to form a hernia of the white line of the abdomen.

When viewed, pay attention to the rounded and sagging shape of the enlarged abdomen in the standing position of the patient and lying down ("frog stomach"), protrusion of the navel, white stretch marks (striae) on the skin at the sides and enlarged and thickened veins form around the navel a picture of the "jellyfish head"

With portal hypertension, jaundice of the skin and sclera, nausea, frequent vomiting are possible.. Tuberculous ascites is accompanied by severe manifestations of intoxication: weakness and unmotivated fatigue, headaches and tachycardia.

Unlike obesity, the patient's body weight is increased disproportionately: arms and legs lose weight significantly

How to identify pathology?

Diagnosis of ascites begins with a medical examination. In addition to visual signs (abdominal enlargement, enlarged venous network, edema of the legs and groin), doctors use percussion.

Tapping with one finger on the other is performed. At the same time, there is a blunting of sound in the supine position in the side channels of the abdomen, on the side - in the lower part. By offering the patient to turn around, one can fix the transition of blunting zones. Another way is one-side jerky movements towards the center, while, on the other hand, a wave is felt.

Ultrasound is performed not only to detect fluid, but also in order to ascertain the cause of ascites. The doctor can examine the liver, reveal the changed sizes, shape, nodal formations. Doppler cartridges assess blood flow in the portal and inferior vena cava.

The liquid on ultrasound has a characteristic picture

An ultrasound examination of the heart allows you to establish signs of heart failure, vices, to notice fluid in the pleural cavity. Inspection of the pancreas is necessary to exclude pancreatitis in the etiology of ascites.

X-ray method is suitable for detection of ascites with a volume of more than 0.5 liters. But the method remains one of the most important in the diagnosis of pulmonary tuberculosis, hypertrophic changes in the heart, pleurisy.

Angiography is a variant of X-ray examination, in which a contrast substance is injected into a vein, and then a series of images are taken to confirm the patency, the shape of the vessels.

Examination of the liver with radioisotope drugs helps to establish the extent of damage to the working cells of the organ. When hepatoscintigraphy is intravenously injected Methionine, labeled with an isotope, sensitive to liver cells. Further scanning allows you to detect areas that are not filled with matter. This means that there are no hepatic cells there, the blanks are filled with fibrous tissue.

Laparoscopic examination under the conditions of the operating unit consists in the introduction through a small incision into the abdominal cavity of an optical technique capable of remotely displaying internal changes in organs.

A special prefix for collecting material for biopsy is used for subsequent histological examination of the liver and other organs, lymph nodes, peritoneum. On the assay must take ascitic fluid, enough 50-100 ml.

Laboratory diagnostics is based on signs of liver disruption, all types of metabolism and electrolyte composition. The following tests are carried out:

• albumin / globulin ratio;
• hepatic transaminases and other enzymes;
• urea, creatinine;
• lipase and amylase of the pancreas;
• potassium, and sodium.

A definite value in the confirmation of the hepatic cause of ascites is given to the study of the parameters of the blood coagulation system. In order to exclude the cancer process in the liver, an assay for the level of α-fetoprotein is prescribed.

The value of the ascites fluid composition in differential diagnostics

Curing ascites without taking into account the underlying disease is impossible. One of the mandatory tests - the study of ascitic fluid obtained with laparoscopy or a special puncture of the abdominal wall. The results help to identify the mechanism of water retention, choose the best drugs and provide treatment for ascites.

First of all, the results should answer the question: "Is the received fluid a transudate or an exudate?". The difference is determined by the content of protein and other components. In the transudate fluid leaves the vascular bed under the influence of increased hydrostatic pressure or a reduced content of colloidal substances, while the vessels themselves remain intact.

In its composition, the transudate contains a protein up to 15 g / l, predominantly in the form of albumins, permissible variations in specific gravity of 1.010-1.015

Exudate - is formed as a result of an inflammatory reaction with damage to the permeability of the vascular wall. The composition of exudate is close to the blood plasma. It includes a significant amount of protein components, which under normal conditions do not pass through the vessel wall (immunoglobulins, fibrinogen, complement).

Total protein is 15-60 g / l. Fibrinogen rapidly transforms into fibrin under the influence of tissue thromboplastins. Filaments of fibrin are visible by microscopy of liquid. The relative density of exudate is 1.015-1.027. Inflammatory elements are necessarily present.

With cirrhosis of the liver, the most common is transudate. Against the background of peritoneal phenomena, inflammation of the internal organs is exudate. The presence of hemorrhagic ascites fluid (with blood) rarely accompanies cirrhosis. Much more often observed with neoplasms, tuberculous peritonitis.

The predominance of neutrophils with a cloudy sediment in the cellular composition of the fluid is a characteristic feature of bacterial peritonitis. If the level of lymphocytes is greatest - peritonitis is more likely of tubercular origin. For diagnosis, such differences are important, since peritonitis can be secretive.

If the resulting material is turbid and whitish (milky), the laboratory assistant assumes that a significant amount of lymph enters the abdominal cavity (chylous ascites). With this variant, the smallest droplets of fat, triglyceride levels, high leukocyte count, tumor cells are found in the composition.

As a confirmation of subjective opinion, laboratory assistants conduct differential diagnostics of samples:

• when the alkaline solution is added, the proteins are dissolved and the turbidity decreases;
• reagents with ether lead to the disappearance of turbidity associated with fats.

A very rare result is the detection of mucus in the ascites fluid. This happens with the pseudomixome of the peritoneum and mucinous adenocarcinoma of the stomach or intestine.

Treatment

There are no standards for ascites therapy. The choice of a doctor depends on the cause of the pathology, the patient's sensitivity to medicines. The longer a patient suffers, the more difficult it is to choose a rational treatment regimen. It is necessary to take into account the activity of the underlying disease. Pathogenetic therapy is carried out.

A patient with ascites needs a half-bed or bed rest. In nutrition, the necessary rule is:

• exclusion of salt - first it is limited to 2 g per day;
• decrease in the fluid.

To monitor the accumulation of water residue daily weighing of the patient, measurement of urine output (urine output per day)

The allowed volume of fluid slightly exceeds diuresis. The optimal weight loss is considered to be up to 500 g. It is impossible to strive for rapid elimination of fluid in therapy. This can cause hypokalemia, contributes to kidney failure.

Therapy with diuretics is carried out under the control of blood electrolytes. Usually prescribe potassium-sparing drugs like Spironolactone. If you can not get the effect, connect Furosemide under the cover of Panangin or Asparkam (provide potassium recovery).

Violation of the protein composition of the blood requires a transfusion of albumin solution or freshly frozen plasma. In the case of congestive events with heart failure, glycosides are required. Other drugs to improve microcirculation, hepatoprotectors take constantly to support blood flow in the portal system and to help the remaining hepatocytes.

Surgical methods - used with ineffective drug therapy. The most commonly used are:

• Laparocentesis- excretion of ascitic fluid through a drainage tube inserted through a puncture of the abdominal wall with a special trocar. Once it is permissible to release 4 liters on a background of drip intravenous compensation. The procedure can be performed fractional for several days, temporarily blocking the drainage.
• Transgular shunting- a serious operation, as a result of which an additional communication is created between the hepatic and portal veins for the discharge of blood and the elimination of portal hypertension.

The method of laparocenesis is owned by therapists, translation into the surgical department is not required

What is the danger of ascites?

Treatment of ascites requires constant attention, the selection of optimal drugs. The lack of dynamics in the patient's condition threatens him with complications:

• bacterial peritonitis;
• the emergence of resistance to diuretic therapy;
• the development of the effects of cirrhosis of the liver - encephalopathy with the loss of a number of brain functions;
• hepatorenal syndrome, adherence of signs of renal insufficiency;
• spontaneous flow of ascitic fluid through the umbilical hernia.

How to treat abdominal ascites in folk ways?

To the popular methods of treating such a difficult condition as ascites, the doctor can advise you to apply only in the calculation for the additional effect of diuretic herbs and plants. The effect really improves when combined with medicines.

The most popular recipes with folk remedies:

• decoction of birch leaves and buds;
• collection of raspberries, cowberries, currant leaves, dog rose;
• berries of juniper, leaves of nettle, linden color;
• parsley and bearberry;
• compote of apricots (contains the necessary potassium).

Ready diuretic collection can be purchased at the pharmacy

Plants have efficacy in the initial stages when the patient follows a diet and regimen. But it is not recommended to arrange for the patient a hot steam room with birch leaves or wraps. This can worsen the state of the heart system.

Can you predict how long the patient will live?

The prognosis of the course of pathology depends on how likely it is to cope with the main cause that caused it. Adverse factors to determine how many live with ascites people suffering from various diseases are:

• elderly patients;
• tendency to hypotension;
• a significant drop in the level of albumin, according to the blood test up to 30 g / l and below;
• concomitant diabetes mellitus;
• reduced glomerular filtration in the kidneys;
• development of peritonitis;
• cancer tumor as the cause of pathology.

According to statistics, 50% of patients with ascites live no more than two years. And with the formation of resistance to diuretics - half die within 6 months of observation. Ascites are a symptom of decompensation. This already indicates that the body has tried all its strength. No matter how we aspire to defeat it, there are no conditions and the opportunity to replace the "tired" bodies.