Ascites - Causes, Symptoms and Treatment .MF .
ascites (ascites, edema of the stomach) - a significant accumulation of free fluid, as a rule, non-inflammatory nature (transudate) in the abdominal cavity.
Causes of ascites
Ascites can occur in various diseases and pathological conditions:
1. When portal hypertension (increased pressure in the portal vein that collects blood from a significant amount of abdominal organs) of various origins with blood flow by blocking the development of the portalvein of the liver level (cirrhosis), nadpechёnochnom (thrombosis of the hepatic veins) or podpechёnochnom level (portal vein thrombosis, and compression of its germination tumors nearby organs).Due to a significant increase in hydrostatic pressure in the portal vein blood plasma system from the veins of the stomach, intestines and spleen propotevaet in the free abdominal cavity, accumulating there.
2. Decompensated chronic heart failure with the development of stagnation in the systemic circulation and edematous syndrome.
3. Kidney disease, accompanied by
5. Development of the obstacles to the outflow of lymph thoracic duct.
6. peritoneal seeding cell cancer (peritoneal carcinomatosis).
7. The defeat of the peritoneum tuberculous process (called ascites-peritonitis).
These causes can combine and exacerbate each other.So, liver cirrhosis develop ascites, in addition to intrahepatic portal hypertension, contributes to the reduction of plasma oncotic pressure due to a reduction in its amount of protein, especially its important species - albumin, due to violation of its formation in the liver with cirrhosis;as well as sodium and water retention in the body due to insufficient inactivation (elimination of biological activity) aldosterone and antidiuretic hormone (hormone regulating water and electrolyte metabolism in the body).
Children ascites may be a manifestation of congenital, hereditary or acquired pathology:
1. In general congenital edema caused by group (AB0) and Rh incompatibility of mother and fetus blood (hemolytic disease of the newborn).Such children are not viable and die, usually within the first hours after birth.
2. In general congenital edema caused by loss of blood hidden fruit.
3. With the defeat of the biliary tract and liver in infants.
4. The investigation of chronic eating disorder in kwashiorkor - a severe degeneration in the background of a lack of protein in the diet.
5. Exudative enteropathy - a hereditary disease caused by loss of blood plasma and plasma proteins through the gastrointestinal tract.
6. Congenital nephrotic syndrome.
older children causes of ascites are largely the same as in adults.
symptoms of ascites
main symptoms of ascites due to the dynamic accumulation of fluid in the abdominal cavity.The beginning of this pathological condition, usually progressive, it develops over a few months, but the portal vein thrombosis can occur rapidly enough.
gradual development of ascites, usually accompanied by flatulence (bloating), manifestations of which may initially dominate the clinical picture.the circumference of the abdomen of the patient gradually increases with the number of transudate in the abdominal cavity.In the upright position the stomach becomes a spherical shape with a protruding forward or droops its lower half, and in the horizontal position takes a kind of spread-eagled form of "frog stomach": flattened in the umbilical region and bulges in the side sections.When the accumulation of significant amounts of liquid is strained abdominal wall and the skin is stretched, thinned and flattened, stomach bulges outward, may appear white stripes on the skin - striae (stretch marks).
When ascites caused by portal hypertension, ascites, unlike other diseases, there is no swelling, hydropericardium (accumulation of fluid in the pericardium) and hydrothorax (accumulation of fluid in the pleural cavity).However, even with such ascites, if it reaches a considerable value, a large amount of transudate leads to compression of the inferior vena cava and the difficulty of outflow of blood from the lower extremities, which can cause swelling in the legs.Also, when ascites caused by portal hypertension can be detected expansion of subcutaneous veins on the lateral surface of the body and around the navel ( "Medusa head").
View abdomen of the patient with ascites caused by liver cirrhosis.increase in abdominal size is noted, the protrusion of the navel, the availability of advanced subcutaneous veins in the anterior abdominal wall ( "head jellyfish»)
survey with ascites
doctor at inspection determines dullness (percussion - tapping on certain parts of the body, followed by analysis of audio effectsoccurring at the same time) of the accumulated fluid in the shelving, or the side of the abdomen, with this stupidity is moved when changing the position of the body, as the fluid flows freely from one department to another abdominal cavity.Furthermore, when applying abrupt shock lung right hand on one side wall of the abdomen doctor left hand attached to the side wall on the opposite side of the abdomen, it feels transmission wave (fluctuation phenomenon).
From instrumental examination methods are most useful ultrasound and computed tomography of the abdominal cavity, which not only can detect even small amounts of free fluid in the abdominal cavity and assess its volume, but also, in most cases, opredilit cause of ascites (cirrhosis of the liver,portal vein tumor compression, etc.).
free liquid with ascites (marked by arrow), detectable by ultrasound of the abdominal cavity
What tests will have to take with ascites
1. Complete blood count: usually does not have an independent diagnostic significance with ascites, soa change in this pathology it is usually not observed.In cases of advanced cirrhosis of the liver, caused ascites, presence of anemia, increased erythrocyte sedimentation rate.
2. Urinalysis: may reflect the characteristic changes with ascites caused by cirrhosis of the liver: proteinuria (protein in the urine excretion), the presence of the cylinder in the urine (cylindruria), red blood cells (microscopic hematuria);as well as ascites caused by kidney disease as a result of the violation of their functions: massive proteinuria, cylindruria, hematuria, high relative density of urine.
3. Biochemical analysis of blood: may reflect changes caused by impaired renal function (hypoproteinemia - a decrease in the protein content of blood plasma, increasing the content of nitrogenous wastes) or hepatic (increase of direct and indirect bilirubin, hypoproteinemia, increased alanine aminotransferase, and others).
4. general analysis obtained by puncture of the abdominal cavity with ascites fluid corresponds transudate: transparent liquid, in some cases, an impurity may comprise or be bloody hilёzny (milky) nature, has a neutral or slightly alkaline reaction, protein content is less than 2,5% (25 g / l), the relative density not exceeding 1.015.
5. sample Rivolta (Rivolta) - quality response to the protein, is used to differentiate transudate from exudate.The acetic acid solution was added 1-2 drops of laboratory test liquid from the abdominal cavity.In an acidic environment dissolved protein is denatured and precipitated.If the incident droplet forms a white haze in the clouds, descending to the bottom of a test tube, positive test, this indicates that the tested fluid is an exudate with a protein content of more than 3%.Drop transudate does not cause turbidity.
6. cytology evacuated puncture the abdominal cavity fluid avoids ascites tumor origin (carcinomatosis of the pleura).To this liquid obtained by puncture and centrifuged precipitate prepared from cytological preparations (smear) which are then subjected to staining by the method Romanovsky - Giemsa.The thus prepared formulations doctor cytologist studies under the microscope.When ascites tumor cells in a smear should not be, but can be detected mesothelial cells lining the inside of the abdominal cavity.
7. bacteriological study of fluid from the abdomen to rule out tuberculous ascites-peritonitis.Seeded fluid obtained by puncture of the abdominal cavity on artificial nutrient media of microorganisms with subsequent evaluation of the results of germination.
treatment of ascites
Treatment of ascites reduced to therapeutic interventions and surgical procedures.
Therapeutic activities are aimed at treating the underlying disease.In order to reduce the delay in the body of sodium chloride salt-free diet is appointed, mechegonnye, drugs - aldosterone antagonists.
In the case of the development of ascites in liver cirrhosis limit the amount of fluid intake to 1.5 liters per day and salt (diet number 7), the amount of protein in the daily diet should be not less than 70-80, the
If you have a patient heartfailure rule psycho-emotional stress, prescribed diet number 10 or number 10 a limited acceptance of water and salt, prescribe drugs, causing increase in a reduced contractility of the myocardium (cardiac glycosides, stimulants β-adrenergic inhibitors fofodiesterazy), drugs that promote excretion of excessive amounts of fluidfrom the body - diuretics (carbonic anhydrase inhibitors, "loop", thiazide and thiazide, potassium-sparing diuretics), and drugs that reduce the load on the left ventricle of the heart (peripheral venous, arterial and mixed vasodilators, ACE inhibitors).
When diseases kidneys, accompanied by the development of nephrotic syndrome (glomerulonephritis, renal amyloidosis) and led to the appearance of ascites, prescribed bed rest, which increases the production of urine, diet number 7 with a significant restriction of reception of salt (up to the total elimination of it fromdiet in patients with severe edematous syndrome), and control the amount of fluid intake, which should not exceed more than 200-300 ml per day the amount of allocated urine.Correction of protein metabolism is carried out at the expense of receipts from food optimal amounts of protein, as well as the purpose of funds, contributing to a decrease in protein loss in the urine (ACE inhibitors);if necessary, pour a 20% albumin solution (100-150 ml of 1 every 2-3 days to 5-6 infusion rate);prescribe diuretics (thiazide, "loop", potassium-sparing diuretics).
Neonates with congenital general edema caused by hidden hemorrhage, symptomatic treatment, which consists in transfusion and blood plasma.When ekksudativnoy enteropathy in children used a transfusion of blood plasma in the calculation of 5-10 ml per 1 kg of body weight of the child, administered glucocorticosteroids, aldactone (veroshpiron).
the presence of a significant volume of ascites resorted to drainage of the abdominal cavity with the gradual removal of her transudate .Prior to this, the patient must empty the bladder.Manipulation is carried out in the sitting position of the patient under local anesthesia, as a rule, at a point midway between the navel and the pubis, where a fine needle is introduced in layers into soft tissue 0.5% novocaine solution volume of 20 ml.Then the surgeon with a scalpel incised the skin and enters the abdominal cavity trocar - a special tool consisting of a sharp stylet, vstalennogo in the hollow shell (tube).After removing the stylet sleeve through channel (tube), the surgeon inserts a trocar into the abdominal cavity drainage, and the case is pulled.In order to avoid a sharp drop in pressure during abdominal ascitic fluid discharging, which may cause collapse (sudden reduction in blood pressure), the fluid evacuation produce slowly and intermittently.For a more complete fluid evacuation as the expiration of her nurse pulls the stomach of the patient with a towel, which encircles the stomach above and below the state drainage.Debilitated patients procedure can be stretched to 8 to 20 hours, followed by drainage from the peritoneal cavity are removed.
the presence of ascites due to portal hypertension, occasionally resorted to a variety of surgical interventions.In the so-called transactions Kalb surgically excised peritoneum and the muscles in the lumbar region, after which the liquid begins to be absorbed subcutaneous tissue (this operation is effective in 30% of cases), but formed a "window" only works for 1-6 months.The most widely forming operation vascular anastomoses between hollow and bottom branches of the portal vein, which leads to a decrease in pressure in the portal venous system and prevents the development of ascites.
the presence of abdominal large amounts of fluid may develop respiratory failure and overload of the right heart due to compression of a raised diaphragm lungs and major blood vessels.In the event of the accession of infection may develop peritonitis (inflammation of the peritoneum), which is a very severe disease requiring urgent surgical intervention.
Prevention Prevention is a timely and adequate treatment of diseases, which in the case of decompensation may lead to its development.
prognosis of ascites largely determined by the underlying disease.It is considered serious if, in spite of an ongoing treatment, the volume of liquid in the abdomen continues to grow rapidly.Prognostic value of ascites is that it exacerbates the growth of the severity of the underlying disease.
Surgeon Kletkin ME