Ascites – the secondary state which is characterized by accumulation of exudate or a transsudat in a free abdominal cavity. Clinically ascites is shown by increase in volume of a stomach, weight, feeling of a raspiraniye and an abdominal cavity pains, short wind. Diagnosis of ascites includes performing ultrasonography, KT, UZDG, diagnostic laparoscopy with a research of astsitichesky liquid. For pathogenetic treatment of ascites it is always necessary to establish the reason which caused a liquid congestion; purpose of diuretics, punktsionny removal of liquid from an abdominal cavity belong to symptomatic actions at ascites.
Ascites or belly dropsy can accompany a current of the most wide range of diseases in gastroenterology, gynecology, oncology, urology, cardiology, endocrinology, rheumatology, a limfologiya. Accumulation of peritonealny liquid at ascites is followed by increase in intra belly pressure, a diaphragm dome pushing off in a chest cavity. At the same time the respiratory excursion of lungs is considerably limited, warm activity, blood circulation and functioning of abdominal organs is broken. Massive ascites can be followed by considerable loss of protein and electrolytic violations. Thus, at ascites respiratory and heart failure, the expressed exchange violations can develop that worsens the forecast of the main disease.
The serous cover of an abdominal cavity is normal – the peritoneum produces the insignificant amount of liquid necessary for the free movement of loops of intestines and the prevention of pasting of bodies. This exudate is soaked up back peritoneum. At a number of diseases sekretorny, rezorbtivny and barrier functions of a peritoneum are broken that leads to developing of ascites.
Ascites often occurs at newborns at a hemolytic disease of a fruit; at children of early age – at a hypotrophy, ekssudativny enteropatiya, a congenital nephrotic syndrome. Development of ascites can accompany various defeats of a peritoneum: the nonspecific, tubercular, fungal, parasitic etiology poured peritonitis; peritoneum mesothelioma, psevdomiksy, peritonealny owing to cancer of a stomach, cancer of a large intestine, a breast cancer, ovarian cancer, endometrial cancer.
Ascites can serve as manifestation of a poliserozit (a simultaneous perikardit, pleurisy and dropsy of an abdominal cavity) which meets at rheumatism, system red a wolf cub, rheumatoid arthritis, uraemia, and also Meygs's syndrome (includes ovary fibroma, ascites and ).
As the frequent reasons of ascites the diseases proceeding with portal hypertensia – increase in pressure in portal system of a liver (a vorotny vein and its inflows) act. Portal hypertensia and ascites can develop owing to cirrhosis, a sarkoidoz, a gepatoz, alcoholic hepatitis; the thrombosis of hepatic veins caused by cancer of a liver, gipernefromy, blood diseases, widespread thrombophlebitis etc.; stenosis (thrombosis) of a vorotny or lower hollow vein; venous stagnation at right ventricular insufficiency.
Proteinaceous insufficiency, diseases of kidneys (the nephrotic syndrome, chronic glomerulonefrit), heart failure, a miksedema, GIT diseases (pancreatitis, a disease Krone, chronic diarrhea), , connected with a sdavleniye of a chest lymphatic channel, limfoangioektaziya and difficulty of a limfoottok from an abdominal cavity contributes to development of ascites.
Thus, the difficult complex of inflammatory, haemo dynamic, hydrostatic, water and electrolytic, metabolic violations can be the cornerstone of pathogenesis of ascites owing to what there is a propotevaniye of interstitsialny liquid and its congestion in an abdominal cavity.
Depending on the reasons ascites can develop suddenly or gradually, accruing for several months. Usually the patient pays attention to change of clothing size and impossibility to button a belt, increase in weight.
Clinical displays of ascites are characterized by feelings of a raspiraniye in a stomach, weight, abdominal pains, a meteorizm, heartburn and an eructation, nausea. In process of increase of amount of liquid the stomach increases in volume, the navel is stuck out. At the same time in a standing position the stomach looks drooped, and in a prone position becomes spread, vybukhayushchy in side departments ("a frog stomach"). At the large volume of a peritonealny exudate short wind, hypostases standing develops, the movements, especially turns and inclinations of a trunk are at a loss. Substantial increase of intra belly pressure at ascites can lead to development of umbilical or femoral hernias, a varikotsela, hemorrhoids, loss of a rectum.
Ascites at tubercular peritonitis is caused by secondary infection of a peritoneum owing to genital tuberculosis or tuberculosis of intestines. Weight loss, fever, the phenomena of the general intoxication are also characteristic of ascites of a tubercular etiology. In an abdominal cavity, except astsitichesky liquid, the increased lymph nodes along a bryzheyka of intestines are defined. The exudate received at tubercular ascites has density> 1016, protein content of 40-60 g/l, positive reaction of Rivalt, the deposit consisting of lymphocytes, erythrocytes, endotelialny cages contains tuberculosis mikobakteriya.
Ascites, the attendant peritonealny , proceeds with the multiple increased lymph nodes which are palpated through a forward belly wall. The leading complaints at this form of ascites are defined by localization of primary tumor. The Peritonealny exudate practically always has hemorrhagic character, sometimes in draft atypical cages are found.
At Meygs's syndrome at patients ovary fibroma (sometimes malignant tumors of an ovary), ascites and comes to light. Belly-aches, the expressed short wind are characteristic. The right ventricular heart failure proceeding with ascites is shown akrotsianozy, hypostases of shins and feet, a gepatomegaliya, morbidity in the right podreberye, gidrotoraksy. At a renal failure ascites is combined with diffusion hypostasis of skin and hypodermic cellulose – an anasarka.
The ascites developing against the background of thrombosis of a vorotny vein has persistent character, is followed by the expressed pain syndrome, a splenomegaliy, insignificant gepatomegaliya. Owing to development of collateral blood circulation quite often there are massive bleedings from gemorroidalny knots or varikozno the increased gullet veins. In peripheral blood anemia, a leykopeniye, thrombocytopenia comes to light.
The ascites accompanying intra hepatic portal hypertensia proceeds with the muscular dystrophy moderated by a gepatomegaliya. On stomach skin at the same time expansion of venous network in the form of "the head of a jellyfish" is well noticeable. At post-hepatic portal hypertensia persistent ascites is combined with the jaundice expressed by a gepatomegaliya, nausea and vomiting.
Ascites at proteinaceous insufficiency, as a rule, small; peripheral hypostases, a pleural exudate are noted. Poliserozita at rheumatic diseases are shown by specific skin symptoms, ascites, availability of liquid in a cavity of a pericardium and a pleura, a glomerulopatiya, artralgiya. At violations of a limfoottok (hilezny ascites) the stomach quickly increases in sizes. Astsitichesky liquid has dairy color, a pastelike consistence; at a laboratory research in it fats and lipoida come to light. The amount of liquid in a cavity peritoneum at ascites can reach 5-10, and sometimes and 20 liters.
Diagnosis of ascites
First of all, it is necessary to exclude other possible reasons of increase in volume of a stomach – obesity, an ovary cyst, pregnancy, tumors of an abdominal cavity etc. For diagnosis of ascites and its reasons percussion and a palpation of a stomach, ultrasonography of an abdominal cavity, UZDG of venous and lymphatic vessels, MSKT of an abdominal cavity, a liver stsintigrafiya, a diagnostic laparoscopy, a research of astsitichesky liquid is carried out.
Stomach percussion at ascites is characterized by obtusion of a sound, shift of limit of dullness at changes of position of a body. Applying of a palm to the side surface of a stomach allows to feel pushes (a fluctuation symptom) at percussion as fingers on an opposite wall of a stomach. The survey X-ray analysis of an abdominal cavity allows to identify ascites at the volume of free liquid more than 0,5 l.
From laboratory tests at ascites the research of a koagulogramma, biochemical tests of a liver, the levels IgA, IgM, IgG, the general analysis of urine is conducted. At patients with portal hypertensia performance of EGDS for the purpose of detection varikozno of the changed veins of a gullet or a stomach is shown. At roentgenoscopy of a thorax liquid in pleural cavities, high standing of a bottom of a diaphragm, restriction of a respiratory excursion of lungs can come to light.
During ultrasonography of abdominal organs at ascites the sizes, a condition of tissues of liver and spleen are studied, tumoral processes and defeats of a peritoneum are excluded. Doppler sonography allows to estimate a blood-groove in vessels of portal system. Gepatostsintigrafiya is carried out for definition of absorbing and excretory function of a liver, its sizes and structure, assessment of expressiveness of tsirrotichesky changes. For the purpose of assessment of a condition of the splenoportalny course the selective angiography – a portografiya (splenoportografiya) is carried out.
To all patients with the ascites revealed for the first time it is carried out diagnostic for a fence and a research of character of astsitichesky liquid: determination of density, cellular structure, amount of protein and bacteriological crops. At difficult differentiable cases of ascites carrying out a diagnostic laparoscopy or laparotomy with an aim biopsy of a peritoneum is shown.
Treatment of ascites
Pathogenetic treatment of ascites demands elimination of the reason of its development, i.e. primary pathology. For reduction of displays of ascites the saltless diet, liquid reception restriction, diuretic medicines are appointed (, furosemide under cover of medicines of potassium), correction of violations of water and electrolytic exchange and decrease in portal hypertensia by means of antagonists of receptors of angiotensin II and APF inhibitors is carried out. Application of gepatoprotektor, intravenous administration of proteinaceous medicines (native plasma, albumine solution) is at the same time shown.
At ascites, resistant to the carried-out medicamentous therapy, resort to an abdominal paratsentez (laparotsentez) – punktsionny removal of liquid from an abdominal cavity. For one puncture it is recommended to evacuate no more than 4-6 l of astsitichesky liquid in view of danger of development of a collapse. Frequent repeated punctures create conditions for an inflammation of a peritoneum, formation of solderings and increase probability of complications of the subsequent sessions of a laparotsentez. Therefore at massive ascites make installation of a constant peritonealny catheter for long evacuation of liquid.
The peritoneovenozny shunt and partial deperitonization of walls of an abdominal cavity belong to the interventions providing conditions for ways of direct outflow of peritonealny liquid. The operations reducing pressure in portal system belong to indirect interventions at ascites. Their number includes interventions with imposing of various portokavalny anastomoz (portokavalny shunting, transjyugulyarny intra hepatic portosistemny shunting, a reduction of a splenic blood-groove), limfovenozny to a soustya. In certain cases at refractory ascites the splenektomiya is made. At resistant ascites transplantation of a liver can be shown.
The forecast at ascites
Existence of ascites significantly makes heavier the course of the main disease and worsens its forecast. Spontaneous bacterial peritonitis, hepatic encephalopathy, a gepatorenalny syndrome, bleedings can become complications of the ascites.
At patients with ascites refer age to adverse predictive factors 60 years, hypotonia (it is lower than 80 mm of mercury), a renal failure, a gepatotsellyulyarny carcinoma, diabetes, cirrhosis, pechenochnokletochny insufficiency, etc. are more senior. Two-year survival at ascites makes about 50%.