Ascites is a secondary condition characterized by the accumulation of exudate or transudate in the free abdominal cavity. Clinically manifested by an increase in abdominal volume, heaviness, a feeling of bursting and abdominal pain, shortness of breath. Diagnosis includes ultrasound, CT, ultrasound, diagnostic laparoscopy with examination of ascitic fluid. For pathogenetic treatment, it is necessary to establish the cause that caused the accumulation of fluid; symptomatic measures for ascites include the appointment of diuretics, puncture removal of fluid from the abdominal cavity.
ICD 10
R18 Ascites
Meaning
Ascites or abdominal dropsy can accompany the course of a wide range of diseases in gastroenterology, gynecology, oncology, urology, cardiology, endocrinology, rheumatology, lymphology. The accumulation of peritoneal fluid in ascites is accompanied by an increase in intra-abdominal pressure, pushing the dome of the diaphragm into the thoracic cavity. At the same time, the respiratory excursion of the lungs is significantly limited, cardiac activity, blood circulation and the functioning of the abdominal organs are disrupted. Massive ascites can be accompanied by significant loss of protein and electrolyte disturbances. Thus, with ascites, respiratory and heart failure, pronounced metabolic disorders can develop, which worsens the prognosis of the underlying disease.
Causes of ascites
Ascites in newborns is often found with hemolytic disease of the fetus; in young children – with hypotrophy, exudative enteropathy, congenital nephrotic syndrome. The development of disease can accompany various lesions of the peritoneum: diffuse peritonitis of nonspecific, tuberculous, fungal, parasitic etiology; mesothelioma of the peritoneum, pseudomyxoma, peritoneal carcinosis due to cancer of the stomach, colon, breast, ovaries, endometrium.
Pathology can serve as a manifestation of polyserositis (simultaneous pericarditis, pleurisy and dropsy of the abdominal cavity), which occurs in rheumatism, systemic lupus erythematosus, rheumatoid arthritis, uremia, as well as Meigs syndrome (includes ovarian fibroma and hydrothorax).
Frequent causes of ascites are diseases occurring with portal hypertension – an increase in pressure in the portal system of the liver (portal vein and its tributaries). Portal hypertension and ascites can develop due to cirrhosis of the liver, sarcoidosis, hepatosis, alcoholic hepatitis; thrombosis of hepatic veins caused by liver cancer, hypernephroma, blood diseases, common thrombophlebitis, etc.; stenosis (thrombosis) of the portal or inferior vena cava; venous stagnation in right ventricular failure.
Protein deficiency, kidney diseases (nephrotic syndrome, chronic glomerulonephritis), heart failure, myxedema, gastrointestinal diseases (pancreatitis, Crohn’s disease, chronic diarrhea), lymphostasis associated with compression of the thoracic lymphatic duct, lymphangiectasis and difficulty in lymph outflow from the abdominal cavity predispose to the development of ascites.
Pathogenesis
Normally, the serous covering of the abdominal cavity – the peritoneum produces an insignificant amount of fluid necessary for the free movement of the intestinal loops and the prevention of organ gluing. This exudate is absorbed back by the peritoneum itself. In a number of diseases, the secretory, resorptive and barrier functions of the peritoneum are disrupted, which leads to ascites.
Thus, the pathogenesis of this disease may be based on a complex complex of inflammatory, hemodynamic, hydrostatic, water-electrolyte, metabolic disorders, resulting in perspiration of interstitial fluid and its accumulation in the abdominal cavity.
Symptoms of ascites
Depending on the causes, the pathology may develop suddenly or gradually, increasing over several months. Usually the patient pays attention to the change in the size of clothes and the inability to fasten the belt, weight gain. Clinical manifestations of ascites are characterized by abdominal distension, heaviness, abdominal pain, flatulence, heartburn and belching, nausea.
As the amount of fluid increases, the abdomen increases in volume, the navel bulges. At the same time, in the standing position, the stomach looks saggy, and in the lying position it becomes flattened, bulging in the lateral sections (“frog belly”). With a large volume of peritoneal effusion, shortness of breath appears, swelling on the legs, movements are difficult, especially turns and tilts of the trunk. A significant increase in intra-abdominal pressure with ascites can lead to the development of umbilical or femoral hernias, varicocele, hemorrhoids, rectal prolapse.
Ascites in tuberculous peritonitis is caused by secondary infection of the peritoneum due to genital tuberculosis or intestinal tuberculosis. Ascites of tuberculous etiology are also characterized by weight loss, fever, and general intoxication phenomena. In the abdominal cavity, in addition to ascitic fluid, enlarged lymph nodes are detected along the mesentery of the intestine. The exudate obtained with tuberculous ascites has a density of > 1016, a protein content of 40-60 g / l, a positive Rivalt reaction, a precipitate consisting of lymphocytes, erythrocytes, endothelial cells, contains Mycobacterium tuberculosis.
Ascites accompanying peritoneal carcinosis occurs with multiple enlarged lymph nodes that are palpated through the anterior abdominal wall. The leading complaints in this form of ascites are determined by the localization of the primary tumor. Peritoneal effusion almost always has a hemorrhagic character, sometimes atypical cells are found in the sediment.
With Meigs syndrome, patients have ovarian fibroma (sometimes malignant ovarian tumors), ascites and hydrothorax. Abdominal pain, pronounced shortness of breath are characteristic. Right ventricular heart failure, occurring with ascites, is manifested by acrocyanosis, swelling of the legs and feet, hepatomegaly, soreness in the right hypochondrium, hydrothorax. With renal insufficiency, ascites is combined with diffuse edema of the skin and subcutaneous tissue – anasarca.
Ascites, which develops against the background of portal vein thrombosis, is persistent, accompanied by severe pain syndrome, splenomegaly, minor hepatomegaly. Due to the development of collateral circulation, massive bleeding from hemorrhoids or varicose veins of the esophagus often occurs. Anemia, leukopenia, and thrombocytopenia are detected in peripheral blood.
Ascites accompanying intrahepatic portal hypertension occurs with muscular dystrophy, moderate hepatomegaly. At the same time, the expansion of the venous network in the form of a “jellyfish head” is clearly visible on the skin of the abdomen. With posthepatic portal hypertension, persistent ascites is combined with jaundice, pronounced hepatomegaly, nausea and vomiting.
Ascites with protein deficiency, as a rule, is small; peripheral edema, pleural effusion are noted. Polyserositis in rheumatic diseases are manifested by specific skin symptoms, ascites, the presence of fluid in the cavity of the pericardium and pleura, glomerulopathy, arthralgia. With violations of lymphatic drainage (chyletic ascites), the abdomen rapidly increases in size. Ascitic fluid has a milky color, pasty consistency; during laboratory examination, fats and lipids are detected in it. The amount of fluid in the peritoneal cavity can reach 5-10, and sometimes 20 liters.
Diagnostics of ascites
During the examination of the gastroenterologist, other possible causes of abdominal volume increase are excluded – obesity, ovarian cyst, pregnancy, abdominal tumors, etc. For the diagnosis of ascites and its causes, percussion and palpation of the abdomen, abdominal ultrasound, ultrasound of venous and lymphatic vessels, abdominal MSCT, liver scintigraphy, diagnostic laparoscopy, ascitic fluid examination are performed.
Percussion of the abdomen is characterized by a dulling of sound, a displacement of the border of dullness with changes in body position. Applying the palm to the side of the abdomen allows you to feel the tremors (a symptom of fluctuation) when tapping your fingers on the opposite wall of the abdomen. An overview radiography of the abdominal cavity makes it possible to identify ascites with a volume of free fluid of more than 0.5 liters.
From laboratory tests for disease, coagulogram, biochemical liver samples, IgA, IgM, IgG levels, and general urine analysis are examined. In patients with portal hypertension, EGD is indicated to detect varicose veins of the esophagus or stomach. Chest X-ray may reveal fluid in the pleural cavities, high standing of the bottom of the diaphragm, restriction of the respiratory excursion of the lungs.
During ultrasound of the abdominal organs with ascites, the size and condition of the liver and spleen tissues are studied, tumor processes and lesions of the peritoneum are excluded. Dopplerography allows you to assess the blood flow in the vessels of the portal system. Hepatoscintigraphy is performed to determine the absorption-excretory function of the liver, its size and structure, and to assess the severity of cirrhotic changes. In order to assess the condition of the splenoportal bed, selective angiography – portography (splenoportography) is performed.
Diagnostic laparocentesis is performed for all patients with ascites detected for the first time to collect and study the nature of ascitic fluid: determination of density, cellular composition, amount of protein and bacteriological seeding. In difficult-to-differentiate cases of ascites, diagnostic laparoscopy or laparotomy with targeted peritoneal biopsy is indicated.
Treatment for ascites
Pathogenetic treatment requires elimination of the cause of fluid accumulation, i.e. primary pathology. To reduce the manifestations of ascites, a salt-free diet, restriction of fluid intake, diuretics are prescribed, correction of water-electrolyte metabolism disorders and reduction of portal hypertension with the help of angiotensin II receptor antagonists and ACE inhibitors is carried out. At the same time, the use of hepatoprotectors, intravenous administration of protein preparations (native plasma, albumin solution) is shown.
With ascites resistant to ongoing drug therapy, abdominal paracentesis (laparocentesis) is resorted to – puncture removal of fluid from the abdominal cavity. For one puncture, it is recommended to evacuate no more than 4-6 liters of ascitic fluid due to the risk of collapse. Frequent repeated punctures create conditions for inflammation of the peritoneum, the formation of adhesions and increase the likelihood of complications of subsequent laparocentesis sessions. Therefore, with massive ascites, a permanent peritoneal catheter is installed for prolonged evacuation of fluid.
Interventions that provide conditions for direct outflow of peritoneal fluid include peritoneovenous shunt and partial deperitonization of the walls of the abdominal cavity. Indirect interventions for ascites include operations that reduce pressure in the portal system. These include interventions with the imposition of various portocaval anastomoses (portocaval bypass surgery, transjugular intrahepatic portosystemic bypass surgery, reduction of splenic blood flow), lymphovenous anastomosis. In some cases, with refractory ascites, splenectomy is performed. In case of resistant ascites, liver transplantation may be indicated.
Prognosis and prevention
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 (SBP), hepatic encephalopathy, hepatorenal syndrome, bleeding. Unfavorable prognostic factors in patients include age over 60 years, hypotension (below 80 mmHg), renal failure, hepatocellular carcinoma, diabetes mellitus, cirrhosis of the liver, hepatic cell insufficiency, etc. According to experts in the field of clinical gastroenterology, the two-year survival rate for this disease is about 50%.
Literature
- Treatment of ascites in cirrhosis. Diuretics, peritoneovenous shunt, and large-volume paracentesis. Arroyo V, Ginès P, Planas R. Gastroenterol Clin North Am. 1992 Mar;21(1):237-56. link
- Ascites: diagnosis and management. Hou W, Sanyal AJ. Med Clin North Am. 2009 Jul;93(4):801-17, vii. link
- Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis. Jeffries MA, Stern MA, Gunaratnam NT, Fontana RJ. Am J Gastroenterol. 1999 Oct;94(10):2972-6. link
- Management of ascites. A review. Watanabe A. J Med. 1997;28(1-2):21-30. link
- Management of ascites. Paracentesis as a guide. Habeeb KS, Herrera JL. Postgrad Med. 1997 Jan;101(1):191-2, 195-200. link
