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Ascites Causes , Diagnosis and Treatment

This article is about Ascites , which is a common sign in many diseases .
Definition of Ascites
Excess fluid in the peritoneal cavity. 

Aetiology
I. Common Causes: 
- Liver cirrhosis (80% of cases of ascites) .
- Malignant invasion of the peritoneum .
- Right ventricular failure.
II. Less Common Causes: 
A. Portal Hypertension with its causes :
1. Suprahepatic causes.           2. Intrahepatic causes. 
3. Infrahepatic causes. 

B. Peritoneal Diseases: 
- Spontaneous bacterial peritonitis .
- Tuberculous peritonitis .
- Pancreatic ascites: complicating Pancreatitis .

C. Part of Generalized Oedema:
1- Nephrotic syndrome. 2- Nephritic syndrome. 3- Nutritional oedema. 

III. Rare causes:

- Thoracic duct obstruction: ( chylous ascites). 
- Meig's Syndrome: Ovarian fibroma, ascites & right pleural effusion. 
- Hypothyroidism .( ++ Cholesterol > deposition in serous membranes .

Clinical Picture

I. Clinical Picture of Ascites
·        Symptoms:
-Abdominal discomfort & distension.
-Dyspepsia & dyspnoea.
- Development of hernia.
·        Signs :
- Inspection:
1.     Abdominal distension, mainly in the flanks,
2.     Signs of increased intra-abdominal pressure (in chronic cases):
- Widening of the subcostal angle.
- Divarication of the recti.
- Umbilicus is shifted down, everted & may be hernia.
3.      Dilated abdominal wall veins: may occur due to either: - Portal hypertension.
- IVC obstruction.
- Compression of IVC by tense ascites.
Differentiation between the 2 main types of abdominal wall veins
- Palpation:
1. Fluid thrill.
2. Liver & spleen may be felt by dipping.
3. Abdominal masses may be felt in TB & malignancy.

 - Percussion:
1. Resonance at the umbilicus & dullness in the flanks.
2. Shifting dullness from side to side.
 - Auscultation:
Venous hum may be heard in portal hypertension.

 II. Secondary Effects of Ascites :
 1. Pleural effusion on the right side may be present, due to defects in the diaphragm allowing ascitic fluid to pass into the pleura .
2. Rise of the diaphragm by ascites causes:
 - Congested neck veins.
- Dullness of the second left space. 
- Dullness at the bases of the lungs.  
- Displacement of cardiac apex up & out.
 These signs disappear when the patients sets and takes deep inspiration.
 III. Clinical Picture of the Cause :
As features of liver failure & portal hypertension in cirrhosis.  

Differential Diagnosis of Ascites

I. From Other Causes of Abdominal Enlargement:
1. Ovarian Cyst.
2. Full bladder.
3.  Pregnancy.
4. Flatulence .
5. Obesity.
II. DD of the Cause of Ascites.

Investigations
1. Ultrasonography
- Will diagnose ascites and its degree.
- Will differentiate free from encysted ascites .
- May detect the cause of ascites e.g. liver cirrhosis.

2. Aspiration of ascitic fluid & its examination for:
-  Color, turbidity, specific gravity, protein content & cells. 
- Cytology for malignant cells.
- Bacteriological examination.
- Type of ascitic fluid .

Treatment of Ascites
I. Treatment of the' Cause.
II.Treatment of ascites due to cirrhosis:
• The treatment aims at improving the patient's life quality.
• One must not treat ascites if there is any evidence of encephalopathy, as treatment of ascites will deteriorate hepatic encephalopathy.
• Follow up during treatment is mandatory  :
-  Daily estimation of urine volume and body weight .
- The aim is loss of 1 kg body weight every 3 days .
- Do not permit more than lkg loss of weight/day.
- Monitoring serum Na, K and creatinine.
The measures for treatment of ascites in cirrhosis are:
1. Diet  : - Salt restriction and high protein diet.
2. Diuretics:
 - Used if weight loss is less than 1 Kg after 3 days on the diet control .
-  We use Frusemide and  spironolacton in the ratio of 40/100 .
-  If the response it not good we can increase the dose gradually up to  160 mg/day frusemide & 400 mg/day spironolacton.

3. Abdominal paracentesis:
- May be used in massive ascites.
- Remove 10 litres each time, with replacement of the proteins lost in the aspirated fluid by IV albumin .
- The patient must restrict salt in diet and he must use diuretics in order to prolong the period between aspirations .
4. Measures tojncreaseo.smotic pressure: 
 Human albumin may be used if there is marked hypoalbuminaemia.
5. Treatment of resistant ascites:
The cause for resistant ascites may be :
- Inadequate salt restriction: treated by strict regimen.
- Severe hypoalbuminaemia : treated by IV albumin. 
- Hyponatraemia: treated by fluid restriction & mannitol.
- Secondary hyperaldosteronism: treated by high dose spironolacton.
- Development of SBP or malignant ascites: treat the cause .

- If ascites is still resistant:

•  This indicates failure of the kidneys to excrete sodium.
•  It is treated by:
A. Abdominal paracentesis: with IV albumin replacement.
B. Le Veen shunt:
-  A tube with one way valve connects between peritoneal cavity & SVC, so it drains the ascitic fluid into the circulation.
-  The shunt is rarely used, as it has many complications .

6. Hepatic transplantation:

This is the best treatment if available, as it treats the cause.

7. Stem cell transplantation:

Is still in the research phase, but the results are promising.
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Tamer Mobarak

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