Advices for Life


December 08, 2016 00:06

Ascites : Causes, Symptoms , Diagnosis, Treatment

Ascites - is a condition in which fluid accumulates in the free abdominal cavity.The most common cause is portal hypertension.The main symptom of ascites - an increase in the size of the stomach.

Diagnosis is based on physical examination, ultrasound, or CT scan.ascites Treatment includes bed rest, diet restricted sodium diet, diuretics and therapeutic paracentesis.Ascites fluid can become infected (spontaneous bacterial peritonitis), which is often accompanied by pain and fever.Diagnosis of ascites includes the research and planting of ascites.ascites treatment based on antibiotic therapy.

What causes ascites?

Typically, a manifestation of ascites (portal) hypertension (& gt; 90%) as a result of chronic liver disease, cirrhosis ending.Other causes of ascites are less frequent and include chronic hepatitis, severe alcoholic hepatitis without cirrhosis and hepatic vein obstruction (Budd-Chiari syndrome).Portal vein thrombosis does not usually cause ascites unless hepatocellular liver amazed structu


Extrahepatic causes of ascites include general fluid retention associated with systemic disease (eg, heart failure, nephrotic syndrome, severe hypoalbuminemia, pinching pericarditis), and diseases of the abdominal cavity (eg, carcinomatosis or bacterial peritonitis, bile leakage after surgery or other medical procedures).Less common causes are kidney dialysis, pancreatitis, systemic lupus erythematosus, endocrine disorders (eg, myxedema).

Pathophysiology of ascites

mechanism of ascites is complex and not fully understood.Known factors include Stirling change in pressure in the vessels of portal vein (low oncotic pressure due to hypoalbuminemia and increased pressure in the portal vein), the active sodium retention by the kidneys (normal concentration of sodium in the urine

mechanisms affecting sodium retentionkidney include activation of the renin-angiotensin-aldosterone system, increased sympathetic tone; intrarenal shunting of blood past the cortex; increased production of nitric oxide, the change generation and exchange of antidiuretic hormone, kinins, prostaglandins, and atrial natriuretic peptide Vasodilation visceral blood flow, is the trigger, but the value of these disorders and the relationship between them are not fully understood.

Spontaneous bacterial peritonitis (SBP) is associated with infection with ascites without apparent source. Spontaneous bacterial peritonitis occurs usually when cirrhotic ascites, most often in patients with alcohol dependence,and often leads to death.It can cause severe complications and death.Most often, spontaneous bacterial peritonitis caused by gram-negative bacteria Escherichia coli and Klebsiella pneumoniae, a Gram-positive and Streptococcus pneumoniae; usually from ascites is sown only one microorganism.

symptoms of ascites

small amount of ascites does not cause symptoms.A moderate amount increases stomach volume and body weight.A large number leads to a nonspecific diffuse abdominal strain without pain.If as a result of ascites poddavlivat diaphragm, shortness of breath may occur.Symptoms of spontaneous bacterial peritonitis can be complemented by a sense of discomfort in the abdomen and fever.

Objective evidence of ascites include displacement dullness to percussion of the stomach and fluctuations.The liquid volume of less than 1500 ml during physical examination can not be diagnosed.Large ascites causes tension of the abdominal wall and the protrusion of the navel.In diseases of the liver ascites or peritoneal lesions are not usually associated with peripheral edema or disproportionate to them;in systemic diseases (eg, heart failure), on the contrary, it is more pronounced peripheral edema.

spontaneous bacterial peritonitis Symptoms may include fever, malaise, encephalopathy, worsening of liver failure and unexplained clinical deterioration.There are signs of peritoneal ascites (eg, abdominal pain on palpation and Shchetkina-Blumberg symptom), but they can be smoothed by the presence of ascites.

Diagnosis of ascites

Diagnosis can be made on the basis of physical examination in case of a significant amount of fluid, but the instrumental studies are more informative.CT and ultrasonography can detect a much smaller volume of liquid (100-200 ml) as compared to physical examination.Suspicion of spontaneous bacterial peritonitis occurs when a patient with ascites, abdominal pain, fever, or unexplained deterioration.

Diagnostic paracentesis dye shows if ascites revealed recently, its cause is unknown or there is a suspicion of spontaneous bacterial peritonitis.Approximately 50-100 ml of fluid is taken for macroscopic evaluation, research on protein content, cell counting and differentiation, cytology, on bacteriological seeding and, if clinically indicated, for painting on the acid resistance of the Ziehl-Nielsen and / or amylase test.In contrast to ascites in inflammation or infection ascitic fluid portal hypertension appears transparent, straw-yellow, has a low protein concentration (typically 4 g / dL) and low amount of PMN (albumin serum as compared with ascitic fluid, which is determined by the difference betweenconcentration of albumin in serum and albumin concentration in ascites (more informative). the gradient of more than 1.1 g / dL indicates that the most likely cause of ascites is portal hypertension. Turbid ascitic fluid and the number of cells 500 PMN / ml indicateinfection, whereas hemorrhagic fluid is usually a sign of a tumor or tuberculosis Milk (chylous) ascites is rare and is usually associated with lymphoma

Clinical diagnosis of spontaneous bacterial peritonitis can be difficult;.. its verification requires careful examination and mandatory diagnostic paracentesis, including bacteriological seedingliquid.Also shown bacteriological blood cultures.Sowing ascites blood cultures prior to incubation increases the sensitivity of almost 70%.Because spontaneous bacterial peritonitis is usually caused by one microorganism detection mixed flora with bacteriological seeding may involve perforation of a hollow organ or contamination of the material.

treatment of ascites

Bed rest and a diet restricted in sodium (20-40 mEq / day) are the basic and the least safe treatment of ascites in portal hypertension.Diuretics have to be applied if a strict limitation on sodium does not cause diuresis sufficient for several days.Usually effective spironolactone (p.o. average 50- 200 mg 2 times a day).In case of insufficient effectiveness of spironolactone may be added to the loop diuretic (e.g., furosemide 20-160 mg orally, typically once a day, or an average of 20-80 mg 2 times a day).As spironolactone can cause potassium retention and furosemide - its excessive excretion, the combination of these drugs often provides optimal diuresis with a small risk of hyper- or hypokalemia.Limit fluid intake is beneficial but only if the content of Na in serum of less than 130 mEq / L.Changes in body weight and the sodium content in urine reflect the efficacy of treatment.Optimal is a loss of about 0.5 kg per day, as the accumulation of ascites can not be more intense.More significant diuresis reduces the volume of intravascular fluid, especially in the absence of peripheral edema;it can cause renal failure or electrolyte imbalance (eg, hypokalemia), which can accelerate the development of portosystemic encephalopathy.Inadequate restriction of sodium in the diet is usually the cause of ascites is constantly continuing.

alternative is therapeutic paracentesis.Removal of 4 liters per day ascites is provided safe intravenous albumin with low salt content (about 40 grams in one procedure) for preventing fluid exiting the vasculature.Therapeutic paracentesis shortens the hospital stay with relatively little risk of electrolyte imbalance or renal dysfunction;however, patients require continued administration of diuretics, and this does not preclude recurrent ascites, and significantly faster than without paracentesis.

Technique autologous infusion of ascitic fluid (eg, shunt peritoneovenozny LeVeen) often leads to complications and are generally no longer used.Transyugulyarnoe intrahepatic portosystemic shunt ( transjugular intrahepatic portal-systemic shunting, TIPS) can reduce portal pressure and allow ascites effectively resistant to other therapies, but involve significant risk and may lead to complications, including portosystemic encephalopathy and worsening hepatocellularfunction.

If there is a suspicion of spontaneous bacterial peritonitis and ascites found more than 500 PMN / ml, should be the appointment of an antibiotic such as cefotaxime 2 g / in every 4-8 hours (Gram stain and evaluation of results of bacteriological seeding) for at least 5 days, while indicators ascites amount not less than 250 PMN / ml.Antibiotics increase the likelihood of survival.Because spontaneous bacterial peritonitis recurs throughout the year in 70% of patients, antibiotic prophylaxis is shown;the most widely used quinolones (e.g. norfloxacin 400 mg / day orally).Prophylactic antibiotics in patients with ascites and bleeding from varicose veins reduces the risk of spontaneous bacterial peritonitis.