Ascites

Ascites is the accumulation of fluid in the abdominal cavity. Causes of ascites: 1) chronic inflammation of peritoneum, mainly tuberculosis: 2) venous congestion in hypertension in the system of portal vein (hepatitis, thrombophlebitis, cirrhosis, Chiari syndrome), when haemodynamic failure of the heart: 3) obstruction of lymphatic drainage; 4) carcinomatosis.
In patients with severe ascites belly big, bulging, some hang in the patient standing position and expands on the side with the patient lying (frog's belly). The region of the navel stuck out. The skin of the abdominal wall smooth, shiny, sometimes with pink stripes. At a percussion of the abdomen at the patient on the back is determined dull sound in the lateral parts of the stomach; in the change of body position localization stupidity changes: if the patient is on the right side - stupidity is only right, if the patient is the dullness in the lower abdomen. Percussion definition of ascites possible the accumulation of at least 1.5-2 litres. The small amount of liquid is sometimes possible to get a dull sound in the navel, if percutiebat bottom on the anterior abdominal wall in the knee-elbow position of the patient. When ascites inflammatory origin of the characteristic distribution of percussion sound, like his change with a change of position of a body can not be observed as a result of fusion of the loops of intestine among themselves and with the abdominal wall, shortening of the mesentery and osmawani liquid. Diagnosis of ascites helps identify fluctuations: when applying hands to one side of the abdomen and tap on the abdominal wall from the other side there is a fluctuation (fluctuation) of the liquid. To eliminate vibration of the abdominal wall assistant applies the palm of ulnar edge on the median line of the abdomen.
To clarify the nature of ascites is crucial to puncture the abdominal cavity. The nature of the fluid distinguish ascites: serous, hemorrhagic (cancer, tuberculosis), jeleznyi (at the break of thoracic duct), fatty or pseudohistory, gall. Puncture produce erh, after emptying the bladder. The patient sits on the edge of the operating table, several back; under the feet of him put a stool. In the home of the patient is put on the edge of the bed. Puncture the trocar doing in the middle between the navel and the pubic hair, falling away from the midline of the abdomen 1-2 cm aside. The skin before puncture treated with alcohol and alcoholic solution poda, the skin and subcutaneous tissue at the site of the puncture anaesthetize injection of 0.25% solution novokaina (3-5 ml). Trocar sterilized by boiling dismantled. The liquid produced in alongside the vessel gradually, with intervals of 1-2 minutes After removal of the trocar wound grease alcoholic iodine solution, apply a sterile dressing. If fluid from the wound stubbornly continues to leak out, you have to apply one skin seam. To analyze the liquid is collected in a sterile tube and putting it under the hole trocar.
Treatment. 1. Eliminating the cause ascites. 2. Diet and medication. Food should be limited to the amount of salt to 1 - 2 g / day, resulting in a gradual increase diureza. This can be achieved by preparing food without salt, eating salt-free bread, butter. The amount of fluid in the conditions of a salt-free diet is usually not restricted. You must also apply periodically diuretics: novori (1 ml intramuscularly 1 - 2 times a week), with preparation of the patient ammonium chloride 3 days prior to the introduction of noworyta: gipotiazid from 50-200 mg / day 3 times a week with daily intake of chloride calcium. More effective introduction of aldactone (from 0,075 up to about 0.3 g per day) within 1-3 weeks and Lazika (from 0.04 to 0.24 g g) inside. The dose of drugs picked individually. 3. Surgical (creation of collateral circulation, the imposition of anastomosis between the inferior Vena and portal veins). 4. Symptomatic (release of liquid). Re destruction of ascitic fluid is ineffective, as it rapidly builds up again. In addition, the removal of fluid leads to a lower level of the blood protein that promotes increase of ascites.

Ascites (ascites; GK. askites, askos - leather bag, belly; synonym abdominal dropsy) - accumulation of fluid in the abdominal cavity. Causes of ascites: 1) increased pressure in the portal vein (the vein thrombosis, compression of the tumor or enlarged lymph nodes); cirrhosis of the liver, hepatitis; thrombosis and the compression of the hepatic veins (syndrome Budd-Chiari) on the background of venous congestion General (heart failure) or a stand-alone (constrictive pericarditis); 2) violations of lymph drainage (jeleznyi ascites); 3) the inflammatory process in the peritoneum is contagious, acute or chronic (abdominal TB), infectious-allergic, with increased vascular permeability (collagenosis, acute glomerulonephritis); non-cancerous peritonitis); 4) lowering oncotic pressure (ascites in General edema - principally, malnutrition, cachexia); 5) bleeding in the abdomen.
The pathogenesis of ascites complicated. So, cirrhosis of the liver ascites plays a role not only increased pressure in the portal vein, and sodium retention as a result of increasing levels of aldosterone and a decrease oncotic pressure (decrease albumin of blood). The same factors play a role in the development of ascites and heart failure.
Clinically when ascites accumulation in the abdominal cavity at least 1 liter of liquid. The highest value for the diagnosis have a thorough percussion belly at various positions, fluoroscopy. In the place of accumulation of fluid percutere is determined by the dullness, the borders of which change with the change of position of a body of the patient (this can sometimes be missing in tuberculous peritonitis). When expressed A. there is a noticeable increase in the abdomen, the protrusion of the umbilicus (Fig. 1), the scars on the skin of the anterior abdominal wall from stretching. When A. caused by stagnation in the system of portal vein, reinforced the pattern of veins in the abdominal wall at the umbilicus ("head of Medusa"), the compression of the Vena cava inferior - on the lateral surface of the abdomen (anastomoses the superior Vena cava). When ascites associated with carcinomatosis, it is sometimes possible to probe easily movable seals. When A. on the ground bleeding in the peritoneum are ekhimozy on the sides of the abdomen or bluish-purple coloring around the navel (the symptom Cullen).
Diagnosis of ascites can be difficult at strong flatulence, obesity with flabby walls, large cyst. Described cases of incorrect diagnoses A. acute extension of the stomach.
To clarify the nature of ascites and its causes is shown puncture (see below Surgical treatment), serving simultaneously and therapeutic purposes, since the release of the liquid resolve difficulties circulation (pressure on the inferior Vena cava) and respiratory (high standing of the diaphragm). In the study of the nature of the fluid distinguish transudate (beats. weight 1005 - 1015, the protein content of less than 2.5%, the reaction of Rivalty negative, cell composition of poor and exudate (beats. weight more 1018, the protein content of above 3%, the reaction of Rivalty positive, a large number of cells). Exudate can be serous, fibrinous, hemorrhagic and jeleznik. The specimens with time enriched with protein and shaped elements, and is formed as an intermediate form ascitic fluid - "transudate-exudate".
The specimens found in heart failure, the stagnation in the system of portal vein (primarily cirrhosis of the liver), the compression of the inferior Vena cava (constrictive pericarditis, tumors of the mediastinum), hepatic vein thrombosis, nephrotic syndrome, and malnutrition. When cancer ascites in half of the cases observed transudate. Exudate is defined in peritonitis (cancer, tuberculosis, infectious), and when ascites on the soil of collagenoses. Hemorrhagic exudate indicates cancer, tuberculosis, acute pancreatitis (rare). Jeleznyi exudate (yellowish, with a large number of fat drops observed due to ascites due to difficulties outflow of lymph through the thoracic duct, often at squeeze the last enlarged lymph nodes or tumor. Unlike jeleznova, pseudohistory exudate (whitish, the proportion below 1012, with a single fat drops) is marked by the break of ovarian cysts. Exudate mixed with gall shows the gap biliary tract; he described and after the puncture biopsy of the liver. For the diagnosis of cancer has a value of Cytology ascitic fluid for diagnosis of tuberculosis - planting on a nutrient medium and vaccination Guinea pig.

Fig. 1. Ascites in cirrhosis.