ascites

Ascites - accumulation of fluid in the abdominal cavity.

The most common cause of ascites - increased pressure in the portal vein (portal hypertension), which result in liver disease (cirrhosis, chronic active or alcoholic hepatitis), congestive heart failure , thrombosis or compression of the trunk or branches of the portal vein (Budd syndrome - Chiari). Less ascites is one of the signs of general edema syndrome with kidney disease, malnutrition, or is caused by lesions of the peritoneum (cancer, tuberculosis and other seeding.) Or thoracic duct. The play a role the pathogenesis of ascites low plasma oncotic pressure due to hypoalbuminemia and high pressure in the portal vein; the emergence and rise of ascites also contributes to violation of the regulation of water-salt metabolism.

Accumulation of fluid in the abdomen (sometimes more than 20 l) leads to an increase in intra-abdominal pressure and marginalization of the diaphragm into the chest cavity. As a result, violated function of the abdominal organs, increases the resistance to blood flow, may be a significant restriction of the respiratory lung movement (up to the development of respiratory failure) and violation of the cardiac activity. Protein concentration in the serosa ascitic fluid is relatively small, but its general loss due to formation of transudate with massive ascites can be very large, especially for frequent repetitive distances fluid by puncturing the abdominal cavity (the loss of protein is combined with salts loss) that results in the development protein deficiency.

Ascites in some cases growing fast (thrombosis of the portal vein, cancerous lesions of the liver and peritoneum), others - gradually, over several months (congestive heart failure , cirrhosis of the liver).

Ascites from clinical symptoms can be detected in the presence in the abdomen is not less than 1 liter of fluid. During the inspection revealed an increase in the abdomen, which is in the vertical position of the patient looks saggy, often marked protrusion of the navel; a patient is in a horizontal position, sprawled belly, side of its departments vybuhayut ( "frog stomach"). In severe portal hypertension on the skin of the abdomen is visible to the extended venous network, due to the development of anastomoses between the portal system and the vena cava. Advanced, swollen and convoluted venous collaterals are located around the navel and moving away from it in the form of rays, forming the characteristic shape ( "Medusa head").

At a percussion of the abdomen revealed a dull sound over the sloping side or part of it, the border dullness moves when changing body position. Hand attached to the side wall of the abdomen on the one hand, the presence of ascites can experience tremors induced tapping fingers of the other hand on the abdomen side opposing wall (symptom fluctuations).

In the presence of ascites, the most important diagnostic task is to determine the underlying disease, if it was not detected before the appearance of ascites. When liver damage or other diseases of the abdominal ascites is usually isolated or disproportionate to peripheral edema; in systemic diseases, in addition to ascites, marked peripheral edema, anasarca, signs of stagnation in the lungs. In severe portal hypertension in patients with liver cirrhosis, ascites, often combined with the bleeding from esophageal varices, and is usually accompanied by the development of collaterals under the skin of the abdomen, liver signs. In heart failure, ascites in addition, there are swelling in the legs and feet, akrotsianoz, signs of myocardial injury and cardiac arrhythmias on the ECG, and in renal failure ascites combined with widespread swelling of the skin and subcutaneous tissue (including face). The isolated ascites, combined with progressive weight loss and signs of intoxication in women requires the exclusion of ovarian cancer. Of great importance is diagnostic puncture of the abdominal cavity with ascites laboratory research. In patients with cirrhosis and congestive heart failure, ascites fluid is typically clear, its relative density not exceeding 1.015, the protein concentration is not higher than 2.5%; liquid contains mainly endothelial cells, but peritoneal irritation as a result of repeated punctures contributes to the appearance of leucocytes. When ascites, caused malignant tumor, ascitic fluid may be detected by admixture of blood, tumor cells. In tuberculous lesions peritoneal ascites fluid also may have haemorrhagic nature contains lymphocytes, it can be detected Mycobacterium tuberculosis. Milk (chylous) ascites occurs in lymphomas. The turbidity of ascites and the presence of a large number of neutrophils indicate infection with possible development of ascites, peritonitis.

Treatment is directed at the underlying disease. Applied also diuretics, aldosterone antagonists, take measures for correction of violations of water-salt metabolism and decrease portal hypertension. In case of failure of medical therapy and ascites build-up of the patient should be sent to the hospital, where he may be made a puncture of the abdominal cavity (paracentesis). It is carried out after emptying the bladder of the patient in the sitting position (seriously ill laid on its side) in compliance with the rules of aseptic and antiseptic. Trocar puncture after local anesthesia is performed by midline of the abdomen between the navel and the pubis or along the line connecting the navel to the iliac crest. It is necessary to let the liquid slowly (because of the danger of collapse) and usually no more than 5 - 6 liters per puncture. Repeated puncture can lead to inflammation of the peritoneum and the fusion of the intestines or omentum to the abdominal wall, which poses a threat of serious complications for subsequent punctures.

The forecast underlying disease worsens with ascites. It is particularly unfavorable at the rapid growth of ascites after repeated punctures.