Ascites - what is it?
Ascites is a secondary condition in which transudate or exudate accumulates in the abdominal cavity. Symptoms of pathology are manifested by an increase in the size of the abdomen, pain, shortness of breath, a feeling of heaviness and other signs.
Ascites in medicine is also called abdominal dropsy, which can accompany many diseases from the field of gynecology, gastroenterology, urology, cardiology, lymphology, oncology, etc. Ascites is not an independent disease, but acts as a symptom of one or another serious disorder in the body. Ascites of the abdominal cavity does not occur with mild pathologies, it always accompanies diseases that threaten human life.
Ascites statistics indicate that more than 70% of adults develop it as a result of liver disease. Tumors of internal organs lead to the development of ascites in 10% of cases, another 5% are due to heart failure and other diseases. While in children, the development of ascites most often signals kidney disease.
It has been established that the maximum amount of fluid accumulating in the abdominal cavity during ascites in a patient can reach 25 liters.
- Causes of ascites
- Ascites symptoms
- Stages of ascites
- Treatment methods
Answers to popular questions:
- How quickly does fluid accumulate in ascites?
- How long do you live with abdominal ascites in oncology?
- Is it possible to do an enema with ascites?
- Can you eat watermelon with ascites?
Causes of ascites
The causes of abdominal ascites are varied and are always associated with some serious disorder in the human body. The abdominal cavity is a closed space in which excess fluid should not form. This place is intended for the internal organs - there is the stomach, liver, gallbladder, part of the intestines, spleen, pancreas.
The peritoneum is lined with two layers: the outer one, which is attached to the abdominal wall, and the inner one, which is adjacent to the organs and surrounds them. Normally, there is always a small amount of fluid between these sheets, which is the result of the work of the blood and lymph vessels in the peritoneal cavity. But this liquid does not accumulate, since almost immediately after excretion it is absorbed by the lymphatic capillaries. The remaining small part is necessary so that the intestinal loops and internal organs can move freely in the abdominal cavity and do not stick to each other.
When there is a violation of the barrier, excretory and resorptive function, the exudate ceases to be normally absorbed and accumulates in the abdomen, as a result of which ascites develops.
The causes of ascites are as follows:
Liver disease. First of all, it is cirrhosis, as well as organ cancer and Budd-Chiari syndrome. Cirrhosis can develop against the background of hepatitis, steatosis, intake of toxic drugs, alcoholism and other factors, but it is always accompanied by the death of hepatocytes. As a result, normal liver cells are replaced by scar tissue, the organ increases in size, squeezes the portal vein, and therefore ascites develops. A decrease in oncotic pressure also contributes to the release of excess fluid, because the liver itself is no longer able to synthesize plasma proteins and albumin. The pathological process is aggravated by a number of reflex reactions triggered by the body in response to liver failure;
Heart diseases. Ascites can develop due to heart failure, or due to constrictive pericarditis. Heart failure can be the result of almost all cardiac diseases. The mechanism of development of ascites in this case will be associated with the fact that the hypertrophied heart muscle is not able to pump the necessary volumes of blood, which begins to accumulate in the blood vessels, including in the inferior vena cava system. As a result of high pressure, fluid will escape from the vascular bed, forming ascites. The mechanism of development of ascites in pericarditis is approximately the same, but in this case the outer shell of the heart becomes inflamed, which leads to the impossibility of its normal filling with blood. In the future, this affects the work of the venous system;
Kidney disease. Ascites is caused by chronic renal failure, which occurs as a result of a wide variety of diseases (pyelonephritis, glomerulonephritis, urolithiasis, etc.). Kidney disease leads to the fact that blood pressure rises, sodium along with fluid is retained in the body, as a result, ascites is formed. A decrease in plasma oncotic pressure, leading to ascites, can also occur against the background of nephrotic syndrome;
Ascites can develop when the lymphatic vessels are damaged. This happens due to trauma, due to the presence in the body of a tumor that gives metastases, due to infection with filarias (worms that lay eggs in large lymphatic vessels);
Various lesions of the peritoneum can provoke ascites, among them diffuse, tuberculous and fungal peritonitis, peritoneal carcinosis, cancer of the colon, stomach, breast, ovaries, endometrium. This also includes pseudomyxoma and peritoneal mesothelioma;
Polyserositis is a disease in which ascites appears in combination with other symptoms, including pleurisy and pericarditis;
Systemic diseases can lead to the accumulation of fluid in the peritoneum. These are rheumatism, rheumatoid arthritis, lupus erythematosus, etc.;
Ascites in newborns also occurs and is most often the result of hemolytic disease of the fetus. It, in turn, develops during intrauterine immunological conflict, when the blood of the fetus and the mother does not combine for a number of antigens;
Protein deficiency is one of the factors predisposing to the formation of ascites;
Diseases of the digestive system can provoke excess fluid accumulation in the abdominal cavity. It can be pancreatitis, chronic diarrhea, Crohn's disease. This also includes any processes occurring in the peritoneum and preventing the lymphatic outflow;
Myxedema can lead to ascites. This disease is accompanied by swelling of soft tissues and mucous membranes, manifests itself in violation of the synthesis of thyroxine and triiodothyronine (thyroid hormones);
Serious inaccuracies in nutrition can cause abdominal ascites. Fasting and strict diets are especially dangerous in this regard. They lead to the fact that the body's protein reserves dry up, the concentration of protein in the blood decreases, which leads to a pronounced decrease in oncotic pressure. As a result, the liquid part of the blood leaves the vascular bed and ascites is formed;
- At an early age, ascites accompanies exudative enteropathies, malnutrition and congenital nephrotic syndrome.
So, at the heart of ascites can be a variety of inflammatory, hydrostatic, metabolic, hemodynamic and other disorders. They entail a number of pathological reactions of the body, as a result of which the interstitial fluid sweats through the veins and accumulates in the peritoneum.
The first symptom of ascites is an unprecedented increase in the abdomen, or rather, its bloating. The main reason for this is that a huge amount of liquid accumulates there, and it practically does not come out. A person usually discovers ascites when he cannot fit into his usual clothes, which until recently fit him in size.
If you have abdominal ascites, then there are probably at least two serious functional disorders in your body that need to be cured. Most often it is a malfunction of the intestines, an upset stomach or liver disease.
The rate of increase in symptoms is directly related to what exactly caused the ascites. The process can progress quickly, or it can take several months.
The following clinical signs are the symptoms of abdominal ascites:
- Feeling of fullness in the abdominal cavity;
- The occurrence of pain in the abdomen and pelvis (abdominal pain);
- Bloating, symptoms of flatulence;
- Belching and heartburn;
- Digestion and urination problems;
- Attacks of nausea;
- Heaviness in the abdomen;
- Enlargement of the abdomen in volume. If the patient is in a horizontal position, then the abdomen bulges out on the sides and resembles the appearance of the abdomen of a frog. When a person is standing, the stomach hangs down;
- Bulging of the navel;
- Symptom of abdominal swaying or fluctuation. Always occurs when the abdominal cavity is filled with fluid;
- The more fluid accumulates in the abdominal cavity, the stronger the shortness of breath becomes, the swelling of the lower extremities increases, the movements become slower. It is especially difficult for the patient to bend forward;
Due to the increase in intra-abdominal pressure, a protrusion of the femoral or umbilical hernia is possible. Against this background, hemorrhoids and varicocele may develop. Rectal prolapse is possible.
The symptoms of ascites will differ slightly depending on the etiological factor that provoked it:
Symptoms of ascites in tuberculous peritonitis. In this case, ascites is a consequence of tuberculous lesions of the reproductive system or intestines. The patient begins to rapidly lose weight, his body temperature rises, the symptoms of intoxication of the body increase. The lymph nodes that run along the intestinal mesentery are enlarged. In the sediment taken by puncture of exudate, in addition to lymphocytes and erythrocytes, mycobacterium tuberculosis will be isolated;
Symptoms of ascites in peritoneal carcinosis. If ascites is formed due to the presence of a tumor in the peritoneum, then the symptoms of the disease will primarily depend on which organ it has affected. Nevertheless, always with ascites of oncological etiology, an increase in lymph nodes occurs, which can be felt through the abdominal wall. Atypical cells will be present in the effusion sediment;
Symptoms of ascites in the presence of heart failure. The patient has a bluish color of the skin. The lower limbs, especially the feet and legs, will swell very much. In this case, the liver increases in size, pains occur, localized in the right hypochondrium. The accumulation of transudate in the pleural cavities is not excluded;
Symptoms of ascites against the background of portal vein thrombosis. The patient will complain of severe pain, the liver increases in size, but not much. There is a high risk of developing massive bleeding from hemorrhoids, or from the veins of the esophagus, which have undergone varicose veins. In addition to the enlargement of the liver, an increase in the size of the spleen is observed.
Other symptoms of ascites:
- If the cause of the pathology is portal hypertension, then the patient greatly loses weight, vomits and vomits. The skin turns yellow, a venous pattern appears on the abdomen like a "jellyfish head";
- Protein deficiency, as the cause of ascites, is indicated by severe swelling of the extremities, accumulation of fluid in the pleural cavity;
- With chylous ascites (at the terminal stage of liver cirrhosis), fluid arrives very quickly, which affects the size of the abdomen;
- Skin symptoms come to the fore with ascites, which develops against the background of rheumatic pathologies.
Stages of ascites
There are three stages of ascites, which are determined by the amount of fluid in the peritoneal cavity:
The first stage is transient ascites. In this case, the volume of liquid does not exceed 400 ml. It is almost impossible to notice the symptoms of ascites on your own. Excess fluid can be seen during instrumental examinations (during an MRI or ultrasound). The work of the abdominal organs is not disturbed due to the accumulation of such volumes of fluid. If a person notices any pathological symptoms in himself, then they will be associated with the underlying disease that provokes ascites.
The second stage is moderate ascites. The volume of fluid simultaneously in the abdominal cavity can reach 4 liters. In this case, the patient already notices alarming symptoms in himself, the abdomen increases and begins to hang down while standing. Dyspnea increases, especially when lying down. The doctor is able to determine ascites based on examination of the patient and palpation of his abdominal cavity.
The third stage is tense ascites. Liquid volumes will exceed 10 liters. At the same time, the pressure in the abdominal cavity increases greatly, which leads to problems with the functioning of internal organs. The human condition is deteriorating and requires immediate medical attention.
Refractory ascites is isolated separately. In this case, the pathology most often does not respond to treatment, and the fluid, despite the ongoing therapy, continues to arrive in the abdominal cavity. The prognosis of the development of the disease is unfavorable for the patient's life.
Methods for the treatment of ascites will be effective only if they are implemented in a timely manner. To begin with, the doctor must assess the stage of the pathology and find out what caused its development.
Therapy is carried out in the following areas:
Medical correction of ascites
The main drugs that help remove excess fluid from the body are diuretics. Thanks to their intake, it is possible to achieve the transition of excess fluid from the abdominal cavity to the bloodstream, which helps to reduce the symptoms of ascites. To begin with, patients are prescribed the lowest dose of diuretics to minimize the risk of side effects. An important principle of treatment with diuretics is a slow increase in diuresis, which will not lead to significant losses of potassium and other important metabolites. The most commonly recommended drugs are Aldactone, Veroshpiron, Triamteren, Amiloride. At the same time, potassium preparations are prescribed. At the same time, hepatoprotectors are introduced into the treatment regimen.
At the same time, doctors carry out daily monitoring of the patient's diuresis and, if the treatment is ineffective, the dose of drugs is increased or replaced with stronger drugs, for example, Triampur or Dichlothiazide.
In addition to diuretics, patients are prescribed drugs aimed at strengthening the walls of blood vessels (vitamin C, vitamin P, Diosmin), as well as drugs that prevent fluid from leaving the vascular bed (Reopolyglyukin).
The introduction of protein substrates improves the exchange of liver cells. Most often, concentrated plasma is used for this purpose, or a solution of Albumin at a 20% concentration.
Antibacterial drugs are prescribed if the disease that caused ascites is bacterial in nature.
The patient's diet should be balanced and high-calorie, which will ensure the body's needs for all the trace elements it needs. It is important to limit the consumption of salt, and it is forbidden to include it in the menu at all.
The amount of fluid consumed should also be adjusted downward. Patients are not recommended to drink more than 1 liter of liquid per day, excluding soups.
It is important that the patient's daily diet is enriched with protein food, but its amount should not be excessive. Fat intake should be reduced, especially for patients in whom ascites was provoked by pancreatitis.
Laparocentesis for abdominal ascites is performed if the patient remains resistant to drug correction. For the outflow of fluid, it is possible to place a peritoneovenous shunt with partial deperitonization of the abdominal walls.
Operations aimed at reducing pressure in the portal system are indirect interventions. These include protocaveal shunting, reduction of splenic blood flow, intrahepatic portosystemic shunting.
As for liver transplantation, it is a very complex operation that can be performed with persistent ascites. But, as a rule, finding a donor for an organ transplant is a difficult task.
Laparocentesis of the abdominal cavity with ascites
Laparocentesis of the abdominal cavity with ascites is a surgical procedure in which fluid from the abdominal cavity is removed by puncture. Do not pump out more than 4 liters of exudate at a time, as this threatens the development of collapse.
The more often puncture is performed for ascites, the higher the risk of developing inflammation of the peritoneum. In addition, the likelihood of adhesion formation and complications from the procedure increases. Therefore, with massive ascites, it is preferable to insert a catheter.
Indications for laparocentesis are tense and refractory ascites. The liquid can be pumped out using a catheter, or it simply flows freely into a prepared vessel after insertion into the abdominal cavity of the trocar.
[Video] Laparocentesis procedure (removal of fluid from the abdominal cavity):
Answers to popular questions:
How quickly does fluid accumulate in ascites? The rate of fluid gain in the abdominal cavity directly depends on the disease causing ascites. This process occurs most slowly in cardiac pathologies, and fastest in malignant tumors and chylous ascites.
How long do you live with abdominal ascites in oncology? Ascites itself does not directly affect the patient's life expectancy. However, its development due to oncological diseases worsens the prognosis for survival. The patient's lifespan depends on the effectiveness of the treatment. It has been established that with frequent relapses of ascites resistant to therapy, more than 50% of patients die within a year.
Is it possible to do an enema with ascites? As a rule, an enema for ascites is performed only in a medical institution as a preparatory measure before surgery.
Can you eat watermelon with ascites? Watermelon with ascites can be included in the menu, since its pulp has a diuretic effect and helps to remove excess fluid from the body.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.