Filling the abdomen with liquid. How to remove fluid from the abdominal cavity with folk remedies? Causes of dropsy of the abdominal cavity

12.03.2020

Abdominal ascites is the accumulation of excess fluid in the abdominal cavity.

It is most commonly caused by cirrhosis of the liver. Other important causes of ascites include infections (acute and chronic, including tuberculosis), malignant neoplasms, pancreatitis, heart failure, hepatic vein obstruction, nephrotic syndrome, and myxedema.

Ascites, i.e. the accumulation of fluid in the free abdominal cavity, occurs from various reasons, most often from general violation blood circulation with predominant venous congestion in the portal vein system with cardiac dropsy, especially with tricuspid insufficiency, with adhesive pericarditis or with isolated portal hypertension - with cirrhosis of the liver, pylethrombosis, compression of the portal vein by enlarged lymph nodes, with general renal, especially nephrotic edema or edema of a different nature - with alimentary and secondary dystrophy, finally, from inflammatory lesions of the peritoneum - with peritonitis, mainly chronic tuberculous, cancerous (with stomach cancer, malignant ovarian tumor, etc.) and others; a congestive and inflammatory cause can be combined.

Hydroceles are usually painless, inflammatory are accompanied by pain and soreness to one degree or another.

With a sluggish filling in a lying patient, the ascitic fluid expands the lateral sections of the flattened abdomen (frog belly), and in the standing patient it hangs downward and forward; with tight filling with liquid, the protruding abdomen does not change shape in any position, when the intestine with its inherent tympanic sound almost does not find the conditions for movement, despite the absence of adhesions. Characterized by the movement of fluid when changing the position of the patient.

With hemorrhage into the abdominal cavity (hemoperitoneum), the area of \u200b\u200bdullness is small, but there is significant swelling due to the accompanying inflammatory paresis of the intestine; muscular protection is also expressed, for example, with a bursting pregnant tube, when a test puncture through the posterior fornix of the vagina makes it possible to establish a diagnosis. A delay in menstruation, sudden pain, spotting from the genitals, fainting, and gynecological examination data helps to recognize acute abdominal syndrome in ectopic pregnancy. A similar picture is given by a rupture of an acutely enlarged, for example, malaria, spleen with a characteristic symptom of phrenic nerve irritation (pain in the left shoulder). In dropsy, the specific gravity of ascitic fluid 1 004-1 014; protein not more than 2-2.5 ° / 00 single leukocytes in the sediment, the color of the liquid is straw or lemon yellow. With peritonitis, fibrin clots are characteristic, formed when the liquid is standing, turbidity of varying degrees. Chylous ascites is observed with rupture of the lactiferous vessels of the mesentery (with cancer, mesenteric tuberculosis lymph nodes), pseudochyletic, due to fatty degeneration of effusion cells in chronic cancer and other peritonitis.

Ascites with isolated and significant portal hypertension leads to the development of roundabout blood circulation such as the head of a jellyfish-supra-umbilical or sub-umbilical when compressed by ascites and the inferior vena cava; inflammatory ascites or general venous congestion with no increase or less increase in pressure in the portal system does not create conditions for the development of roundabout blood circulation.

The most common cause of ascites is portal hypertension. Symptoms are usually due to abdominal distension. Diagnosis is based on physical examination and often on ultrasound or CT. Treatment includes rest, a salt-free diet, diuretics, and therapeutic paracentesis. Diagnosis of infection includes analysis of ascitic fluid and culture. Treatment is with antibiotics.

Causes of abdominal ascites

The distribution of fluid between vessels and tissue space is determined by the ratio of hydrostatic and oncotic pressure in them.

Portal hypertension, in which the total blood supply increases internal organs.
Changes in the kidneys, contributing to increased reabsorption and sodium and water retention; these include: stimulation of the renin-angiotensin system; increased secretion of ADH ;,
Imbalance between the formation and outflow of lymph in the liver and intestines. Lymphatic drainage is not able to compensate for the increased flow of lymph, associated mainly with an increase in pressure in the sinusoids of the liver.
Hypoalbuminemia. The leakage of albumin with lymph into the abdominal cavity contributes to an increase in intra-abdominal oncotic pressure and the development of ascites.
Increased serum vasopressin and epinephrine levels. This response to a decrease in BCC further enhances the influence of renal and vascular factors.

Ascites can be caused by liver disease, usually chronic, but sometimes acute, and ascites can also be caused by causes not related to liver pathology.

Hepatic causes include the following:

Portal hypertension (\u003e 90% in liver disease), usually as a consequence of liver cirrhosis.
Chronic hepatitis.
Severe alcoholic hepatitis without cirrhosis.
Hepatic vein obstruction (eg, Budd-Chiari syndrome).

In portal vein thrombosis, ascites usually does not occur, except in cases of concomitant hepatocellular injury.

Extrahepatic causes include the following:

Generalized fluid retention (heart failure, nephrotic syndrome, severe hypoalbuminemia, constrictive pericarditis).
Diseases of the peritoneum (eg, carcinomatous or infectious peritonitis, bile leakage caused by surgery or other medical procedures).

Pathophysiology

The mechanisms are complex and incompletely understood. Factors include changes in portal vascular Starling forces, renal sodium retention, and possibly increased lymph production.

Symptoms and signs of abdominal ascites

Large amounts of fluid can cause a bloating feeling, but real pain is rare and suggests another cause of acute abdominal pain. If ascites causes the diaphragm to stand high, shortness of breath may occur. Symptoms of SBP may include new complaints of abdominal discomfort and fever.

Clinical signs of ascites include dullness on abdominal percussion and fluctuation on physical examination. Volumes<1 500 мл могут не выявляться при физикальном исследовании. При заболеваниях печени или брюшины обычно наблюдается изолированный асцит, либо он диспропорционален перифирическим отекам; при системных заболеваниях обычно встречается обратная ситуация.

Possible hernia of the white line of the abdomen or umbilical hernia, edema of the penis or scrotum, right-sided pleural effusion.

Diagnostics of the abdominal ascites

The detection of ascites with a volume of more than 2 liters does not cause difficulties, but a smaller amount of ascites fluid is not always determined by physical examination. The identification of liquid with the help of percussion is possible only in cases where its volume exceeds 500 ml. The diagnostic accuracy of all described techniques is only 50%.

Radiation diagnostics

With a plain radiograph of the abdomen, there may be a general blurred image and the absence of a shadow of the psoas muscle. As a rule, centralization and separation of intestinal loops is characteristic.
With ultrasound, which is carried out with the patient lying on the right side, even 30 ml of ascitic fluid can be detected. With ultrasound, the presence of both free and encapsulated fluid is determined.
A CT scan of the abdomen can detect mild ascites while assessing the size and condition of the abdominal organs.

Study of ascitic fluid

Diagnostic laparocentesis.The procedure is carried out under aseptic conditions using a vascular catheter with a diameter of 20-23 G. The needle is most often inserted along the white line of the abdomen just below the navel, it can also be inserted into the iliac fossa. Severe complications of laparocentesis (bowel perforation, bleeding, constant outflow of ascitic fluid) are observed in less than 1% of cases.

Laboratory research

For diagnostic purposes, approximately 50 ml of ascitic fluid is required. Pay attention to its appearance and color, determine the number of erythrocytes and leukocytes, the percentage of neutrophils, the level of total protein, albumin, glucose, triglycerides and amylase activity. In parallel, the same indicators are examined in serum samples. Ascitic fluid is cultured immediately (similar to blood culture). In addition, the samples are stained according to Gram and Ziehl-Nielsen, inoculated on media for mycobacterium tuberculosis and fungi, cytological examination is carried out in order to identify malignant cells. Gram staining is informative only for intestinal perforation.
Ascitic fluid typically contains less than 500 μl -1 leukocytes, with neutrophils accounting for less than 25%. If the number of neutrophils is more than 250 μl -1, a bacterial infection is very likely - either primary peritonitis or a consequence of gastrointestinal perforation. If there is an admixture of blood in the ascitic fluid, an amendment must be introduced when calculating the number of neutrophils: for every 250 erythrocytes, one is subtracted from the total number of neutrophils. Lactate and ascitic fluid pH do not play a role in the diagnosis of infection.
The presence of blood in the ascitic fluid indicates an infection with Mycobacterium tuberculosis, fungi, or, more often, a malignant neoplasm. Pancreatic ascites is characterized by high protein content, increased neutrophil counts, and increased amylase activity. Elevated triglyceride levels in ascitic fluid are characteristic of chylous ascites, which develops as a result of obstruction or rupture of the lymphatic vessels from trauma, lymphoma, other tumors, or infections.

Inflammatory ascites occurs in young people more often with tuberculous peritonitis (polyserositis), in the elderly, with a cancerous neoplasm of the stomach and other organs, for example, after surgical removal of breast cancer due to seeding, etc. Cancer ascites often proceeds with deep cachexia, feverlessly, although there are exceptions. To establish the true cause, a complete examination of the patient is required in each case.

Erroneous recognition of ascites is possible with a fat sagging abdomen, with enteroptosis, as well as with severe flatulence. A general increase in the abdomen due to flatulence is possible if both the small and large intestines are significantly swollen; with a predominant swelling of the large intestine, horseshoe-shaped stretching prevails along the colon; with predominant stretching of the small intestines, stretching of the central peri-umbilical region (mesogast-rium) prevails. With peritonitis and peritonism, a sharp swelling of the intestines is often observed early. Significant expansion of the stomach, especially after operations on it, disappears after gastric emptying. With megacolon, asymmetric distension of the abdomen is found mainly due to the sigmoid colon, which in this disease reaches the size of a “car tire” with general exhaustion and flabby muscles of the patient. Megacolon is detected by sluggish peristaltic waves and fluctuations in the size of the abdomen, depending on bowel movements. A contrast enema gives a sharply different picture from the norm, and a lot of fluid is required to fill the large intestine. The disease proceeds with persistent constipation.

With large ovarian cysts, most often leading to erroneous recognition of ascites, it is possible to trace the growth of the tumor from the depth of the small pelvis, protrusion of the navel is almost not observed, gynecological examination establishes a connection between the tumor and the uterus. The tumor may be somewhat asymmetric. The latter is even more pronounced with large hydronephrosis, which sharply change the configuration of the abdomen. A rapid increase in the size of the abdomen can also be observed with a rare false mucus of the peritoneum (pseudomyxoma peritonaei), coming from a burst ovarian cyst or vermiform appendix.

Diagnosis

Ultrasound or CT if obvious physical signs are insufficient.
Frequently investigated parameters of ascitic fluid.

Diagnosis may be based on physical examination in case of large amounts of fluid, but imaging is more sensitive. Ultrasound and CT scans measure much smaller volumes of fluid than a physical exam. SBP should also be suspected if the patient has ascites with abdominal pain, fever, or an unexplained deterioration.

Diagnostic paracentesis should be performed in the following cases:

newly diagnosed ascites;
ascites of unknown etiology;
suspicion of an SBP.

Approximately 50-100 ml of liquid is evacuated and analyzed for general external examination, determination of protein content, counting cells and their types, cytology, inoculation for culture and, if clinically indicated, special studies are carried out for amylase and acid-fast microorganisms. In contrast to ascites due to inflammation or infection, ascites in portal hypertension is characterized by a clear, straw-colored fluid with a low content of protein and polymorphonuclear leukocytes (<250 клеток мкл) и, что наиболее надежно, высоким сывороточно-асцитическим альбуминовым градиентом, который представляет собой разницу уровня сывороточного альбумина и уровня альбумина асцитической жидкости. Градиент > 1.1 g / dL is relatively specific for portal hypertension-induced ascites. If the ascitic fluid is cloudy and the polymorphonuclear leukocyte count is\u003e 250 cells / μL, this indicates SBP, while the fluid with an admixture of blood suggests a tumor or tuberculosis. Rare milk-like (chylous) ascites is most often a sign of lymphoma or an obstructed lymphatic duct.

Primary peritonitis

Primary peritonitis is observed in 8-10% of patients with alcoholic liver cirrhosis. The patient may not have any symptoms, or there may be a detailed clinical picture peritonitis, liver failure and encephalopathy, or both. Without treatment, mortality from primary peritonitis is very high, so in this case it is better to prescribe unnecessary antibacterial agents than to delay their appointment. After receiving culture results, antibiotic therapy can be adjusted. Usually, intravenous administration of antibacterial agents for 5 days is sufficient even with bacteremia.

Most often, bacteria that live in the intestine, such as Escherichia coli, pneumococci and Klebsiella spp., Are detected in ascitic fluid. Anaerobic pathogens are rare. In 70% of patients, microorganisms are also sown from the blood. A number of factors are involved in the pathogenesis of primary peritonitis. It is believed that an important role is played by the reduced activity of the reticuloendothelial system of the liver, as a result of which microorganisms from the intestine enter the blood, as well as the low antibacterial activity of ascitic fluid, which is due to a reduced level of complement and antibodies and impaired neutrophil function, which leads to suppression of opsonization of microorganisms. Pathogens can enter the bloodstream from the gastrointestinal tract through the intestinal wall, from the lymphatic vessels, and in women also from the vagina, uterus and fallopian tubes. Primary peritonitis is often recurrent. The likelihood of relapse is high when the protein content in the ascitic fluid is less than 1.0 g%. The frequency of relapses can be reduced by the administration of fluoroquinolones (eg, norfloxacin) by mouth. Prescribing diuretics for primary peritonitis can increase the opsonizing capacity of ascitic fluid and total protein levels.

Sometimes primary peritonitis is difficult to distinguish from secondary peritonitis caused by abscess rupture or intestinal perforation. The number and type of microorganisms detected can help here. Unlike secondary peritonitis, in which several different microorganisms are always sown at once, with primary peritonitis in 78-88% of cases, the pathogen is one. Pneumoperitoneum almost unambiguously indicates secondary peritonitis.

Complications of abdominal ascites

Most often, shortness of breath, weakening of cardiac activity, loss of appetite, reflux esophagitis, vomiting, hernia of the anterior abdominal wall, leakage of ascitic fluid into the chest cavity (hydrothorax) and scrotum.

Treatment of abdominal ascites

Bed rest and diet.
Sometimes spironolactone, possibly with the addition of furosemide.
Sometimes therapeutic paracentesis.

Bed rest and a sodium-restricted diet (2,000 mg / day) is the first and safest treatment for ascites associated with portal hypertension. Diuretics should be used if the diet is ineffective. Spironolactone is usually effective. A loop diuretic should be added if spironolactone fails. Since spironolactone can cause potassium retention, and furosemide, on the contrary, promotes its excretion, the combination of these drugs often leads to optimal diuresus low risk rejected in the content of K. Restriction in patient fluid intake is indicated only in the treatment of hyponatremia (serum sodium 120 mEq / l) ... Changes in patient weight and urinary sodium levels reflect response to treatment. Weight loss of about 0.5 kg / day is optimal. Bring more intensive diuresis! to a decrease in fluid in the vascular bed, especially in the absence of peripheral risks; which is the risk of developing renal failure or electrolyte disturbances (for example, hypokalemia), which, in turn, contributes to the development of portosystemic encephalopathy. Inadequate sodium reduction in the diet is a common cause of persistent ascites.

The alternative is therapeutic paracentesis. Removing 4 liters per day is safe; many clinicians prescribe intravenous albumin-free intravenous administration (about 40 g for paracentesis) to prevent circulatory disorders. Even a single total paracentesis can be safe.

In uncomplicated ascites, treatment begins with an attempt to normalize liver function. The patient should refrain from taking alcohol and hepatotoxic drugs. Nutrition is a must. If appropriate, drugs are prescribed to suppress inflammation of the liver parenchyma. Regeneration of the liver leads to a decrease in the amount of ascitic fluid.

The drug of choice in most cases is spironolactone. The effect of the drug (suppression of the action of aldosterone in the distal tubules) develops slowly, increased diuresis can be observed 2-3 days after the start of therapy. Possible side effects include gynecomastia, galactorrhea, and hyperkalemia.
If it is not possible to achieve sufficient diuresis with the appointment of spironolactone, furosemide can be added.
Combined therapy.

Taking drugs once a day is most convenient for patients. Amiloride acts faster than spironolactone and does not cause gynecomastia. However, spironolactone is more readily available and cheaper. If spironolactone, in combination with furosemide, does not increase the sodium content in the urine or reduce the patient's weight, the doses of both drugs are simultaneously increased. Doses can be increased even further, but the sodium level in the urine hardly increases. In these cases, the addition of a third diuretic, such as hydrochlorothiazide, may increase urinary sodium excretion, but there is a risk of hyponatremia. When spironolactone and furosemide are prescribed in the above ratios, the plasma potassium content usually remains normal; in case of deviations, the doses of drugs can be adjusted.

Treatment for persistent ascites

In addition to hepatorenal insufficiency, the causes of persistent ascites may be a complication of the underlying liver disease, for example, active hepatitis, thrombosis of the portal or hepatic vein, gastrointestinal bleeding, infection, primary peritonitis, wasting, hepatocellular carcinoma, associated heart or kidney disease, as well as taking hepatotoxic (for example , alcohol, paracetamol) or nephrotoxic substances. NSAIDs reduce renal blood flow by suppressing the synthesis of vasodilating prostaglandins, negatively affecting GFR and the effectiveness of diuretics. ACE inhibitors and some calcium antagonists decrease peripheral vascular resistance, effective BCC, and renal perfusion.

At present, with the ineffectiveness of drug therapy (10% of cases), therapeutic laparocentesis, perito-neovenous shunting or liver transplantation are performed. Previously, for persistent ascites, side-to-side portocaval shunting was used, but postoperative bleeding and the development of encephalopathy due to portal-systemic shunt led to the abandonment of this practice. The efficacy of transjugular intrahepatic portocaval shunting in ascites refractory to diuretic therapy is not yet clear.

Therapeutic laparocentesis... In addition to the fact that the procedure is time-consuming for both the doctor and the patient, it leads to the loss of protein and opsonins, while diuretics do not affect their content. Decreased opsonins may increase the risk of primary peritonitis.

The question of the advisability of introducing colloidal solutions after removing a large amount of ascitic fluid has not yet been resolved. The cost of one albumin infusion ranges from USD 120 to USD 1250. Changes in the level of plasma renin, electrolytes and serum creatinine in patients who have not been infused with colloidal solutions, apparently, have no clinical significance and do not lead to an increase in mortality and the number of complications.

Bypass surgery... In about 5% of cases, the usual doses of diuretics are ineffective, and increasing the dose leads to impaired renal function. In these cases, shunting is indicated. In some cases, side-to-side portocaval shunting is performed, but it is associated with high mortality.

Peritoneovenous shunting, for example, according to Le Vine or Denver, can improve the condition of some patients. In most cases, the patient still needs diuretics, but the dose can be reduced. In addition, renal blood flow is improved. In 30% of patients, shunt thrombosis develops and requires replacement. Peritoneovenous shunting is contraindicated in patients with sepsis, heart failure, malignant neoplasms, and a history of varicose vein bleeding. The frequency of complications and the survival rate of patients with liver cirrhosis after peritoneovenous shunting depends on how much the function of the liver and kidneys is reduced. The best results were obtained in a few patients with persistent ascites and at the same time relatively intact liver function. Nowadays, peritoneovenous shunting is performed only for those few patients in whom neither diuretics nor laparocentesis give a result, or with ineffective diuretics in patients who take too long to get to the doctor to undergo therapeutic laparocentesis every two weeks.

For persistent ascites, orthotopic liver transplant in the presence of other indications for her. One-year survival rate of patients with refractory ascites drug treatment, is only 25%, but after liver transplantation it reaches 70-75%.

Abdominal ascites is a pathology characterized by the accumulation of fluid in the abdomen. Such a violation is considered a complication of a number of extremely life-threatening diseases. Usually, ascites is progressive. With a small volume, fluid in the abdomen can dissolve on its own if the treatment of the primary disease is effective.

In severe forms of this disorder, more than 15 liters of transudate can accumulate in the abdomen, which can no longer find a way out on its own.

Gradually, the accumulation of fluid in the abdominal cavity not only becomes the cause of mechanical compression of organs, but also predisposes to the emergence of a number of dangerous complications. Often, patients with a severe form of edematous-ascites syndrome develop obstruction due to compression of the intestine, as well as peritonitis, since the transudate, the amount of which in the abdomen increases, is an ideal breeding ground for microflora.

Etiology of abdominal ascites

Many diseases can cause abnormal fluid accumulation. Often men with alcohol addiction suffer from this disorder. Alcohol cannot directly provoke edematous-ascitic syndrome, but at the same time the products of its decay quickly destroy the liver. This organ is a multifunctional natural laboratory. It is the liver that is responsible for the production of proteins that regulate the degree of permeability of both blood and lymph vessels. Frequent intake of alcoholic beverages contributes to the destruction of the tissues of this organ. Most people long years suffering from alcohol addiction, severe forms of cirrhosis are diagnosed. At the same time, the liver tissues are so destroyed that they cannot cope with their functions.

Causes and risk groups

In 70% of cases of ascites manifestations, cirrhosis plays an important role. With a severe form of liver damage, accompanied by the accumulation of fluid in the abdomen, the prognosis is poor.

Often, ascites of the abdominal cavity develops against the background of diseases accompanied by portal hypertension. Such pathological conditions include:

sarcoidosis;
hepatosis;
hepatic vein thrombosis in the presence of cancer;
widespread thrombophlebitis;
stenosis of the inferior genital or portal vein;
venous congestion;
alcoholic hepatitis.

The accumulation of fluid in the abdomen can be a consequence of various diseases of the kidneys, gastrointestinal tract and heart. A similar complication often accompanies such pathological conditions as:

myxedema;
glomerulonephritis;
nephrotic syndrome;
heart failure;
pancreatitis;
crohn's disease;
lymphostasis.

Often, edematous-ascites syndrome develops against the background of oncological processes in the body. Often, a similar complication is observed when malignant tumors of the large intestine, stomach, ovaries, breast and endometrium are affected.

A number of factors predisposing to the appearance of ascites are distinguished. Chronic hepatitis, alcohol abuse, injection drug administration, blood transfusion, living in areas with unfavorable environmental conditions, obesity, tattooing significantly increase the risk of developing such a problem. high level cholesterol and diabetes 2 types. This is far from full list factors contributing to the development of ascites.

In newborns, ascites is often found with the development of hemolytic disease of the fetus, which occurs during pregnancy. In young children, fluid in the abdominal cavity may begin to accumulate due to hemolytic disease, exudative enteropathy, malnutrition, congenital nephrotic syndrome.

Determining the root cause of the problem is critical to effectively treating ascites.

To prevent the re-accumulation of fluid in the abdomen, it is necessary to direct efforts to eliminate the underlying disease.

Pathogenesis of ascites development

The peritoneum performs several important functions at once, including fixing the organs located in this area, at anatomical places, and also protects them from injury. Anyone healthy person between the layers of the peritoneum there is a little fluid, the volume of which is maintained normally by means of an extensive network of lymphatic vessels. The transudate is constantly circulating here, that is, the old one is absorbed, and a new one comes in its place. However, certain serious illnesses and pathologies can upset this subtle natural mechanism.

Ascites develops when fluid secretion into the abdominal cavity is disturbed, the process of its reabsorption, or there is a decrease in the barrier to toxins.

Gradually, the volume of fluid increases, which leads to the appearance of a number of complications. Compensatory mechanisms are triggered first, therefore lymphatic system begins to work at the limit of its capabilities, pumping more than 15 liters of fluid per day, taking it away from the liver. Normally, the volume of the pumped lymph when it is diverted from this organ is about 7-8 liters. The venous network is unloaded, which contributes to a temporary improvement in general condition. In the future, the overloaded lymphatic system can no longer cope with this task. Oncotic pressure is significantly reduced, and the volume of interstitial fluid increases. Due to these pathological processes, sweating of the transudate is observed, where it accumulates.

Symptomatic manifestations of fluid accumulation in the abdomen

Despite the gradual development of edematous-ascitic syndrome, a rapid variant is also possible. There are 3 main stages of pathology: transient, moderate and intense. The nature of the symptomatic manifestations depends entirely on the amount of accumulated fluid.

With transient ascites, the transudate volume does not exceed 400 ml. In this case, only swelling is observed.
With moderate ascites, about 5 liters of fluid can accumulate in the abdomen. In this case, the manifestations become pronounced. The patient begins to notice problems with the work of the digestive system and the growing signs of heart and respiratory failure.
Tense ascites is diagnosed when the volume of fluid accumulating in the abdomen varies from 5 to 20 liters. At this stage of the development of the pathology, the patient's condition becomes extremely difficult, as disruptions in the work of a number of vital organs are increasing.

Usually edematous ascites syndrome develops gradually. With this classic version, the patient notices that his belly is slowly increasing in size. As a rule, there are no pronounced signs of a problem at first, but the size of the clothes gradually increases. In some cases, the patient may be worried about unreasonable weight gain. A noticeable increase in size is observed exclusively in the abdomen. When more than 3-5 liters of fluid accumulates in the abdominal cavity, pronounced signs of ascites appear. These include:

feeling of fullness;
nausea;
belching
abdominal pain;
heartburn;
protrusion of the navel;
heartache;
swelling of the abdomen in the sides;
swelling of the legs;
dyspnea;
difficulty turning;
gurgling with sudden movements.

The accumulation of a significant volume of transudate in the abdominal cavity is accompanied by the appearance of a number of complications. Often, due to increasing pressure, umbilical and femoral hernias develop. In addition, severe ascites can lead to rectal prolapse. In some cases, edematous-ascites syndrome leads to the appearance of hemorrhoids and varicocele in men. Compression of the organs located in the abdominal cavity often causes the development of obstruction and accumulation of feces.

The accumulating fluid creates the prerequisites for the development of peritonitis. Transudate contains a large amount of protein, therefore it is an excellent breeding ground for pathogenic microflora. The development of peritonitis against the background of ascites is usually fatal. A significant increase in the volume of transudate becomes the cause of disruption of the work of all vital organs.

Methods for the diagnosis of abdominal ascites

The process of detecting the accumulation of fluid in the abdomen is currently not difficult. First of all, the doctor gets acquainted with the anamnesis to identify diseases that can provoke the development of such a pathology, and also conducts percussion, that is, tapping.

Even slight clicks in the abdomen cause vibrational movements of the liquid inside. With the accumulation of a large amount of transudate, if you put your palm on one side of the abdomen and slap on the other, a pronounced fluctuation is observed.

To confirm the presence of fluid in the abdominal cavity, computed tomography and ultrasound are performed. In addition, to make a diagnosis, general and biochemical analyzes blood and urine. Fluoroscopy may be required depending on the patient's history chest, study of fluid taken from the abdomen, dopplerography, selective angiography and hepatoscintigraphy. If it is not possible to identify the root cause of the complication, diagnostic laparoscopy is performed, which allows you to remove all the fluid and make a biopsy of the peritoneum.

Conservative therapy of ascites

To prevent the accumulation of transudate in the abdomen, the primary disease must be treated first.

Especially important complex therapy with heart failure, tumors and liver damage.

If there is transient ascites, clear improvement can be achieved with conservative means. The patient is prescribed a strict salt-free diet for abdominal ascites. The diet must include foods high in potassium. These include:

baked potato;
dried apricots;
spinach;
raisins;
grapefruit;
asparagus;
green pea;
carrot;
oat groats.

Despite the fact that the diet has many restrictions, it must be designed so that the patient's body receives all the necessary proteins, fats, vitamins and minerals. Depending on the characteristics of the primary disease, the list of foods that are recommended to be excluded from the diet may vary significantly.

The amount of liquid consumed per day should be limited to 1 liter.

In addition, it is prescribed medicines, contributing to the restoration of water and electrolyte balance.

Diuretics can have a significant positive effect, but they should be used with extreme caution. With a moderate stage of ascites, in addition to drugs and diet, puncture removal of fluid from the abdomen is limited. Abdominal laparocentesis with ascites can quickly improve the patient's condition. Up to 5 liters of transudate can be eliminated in one puncture. It is not recommended to immediately remove a large amount of fluid, since collapse may develop due to the rapid decrease in intra-abdominal pressure. In addition, this method of treatment creates optimal conditions for inflammation, infection, adhesions and other complications. This method of treatment is effective when unstressed ascites is present. In severe cases, when frequent evacuation of fluid from the abdomen is required, an indwelling peritoneal catheter is inserted. When ascites progresses, treatment can only slow the process down.

Surgical treatment of ascites

Surgical interventions to eliminate fluid from the abdominal cavity are used only in severe cases when other methods are not effective or there are complications of the pathology. For example, when a transudate is infected with microflora and peritonitis develops, all accumulated fluid is removed and the intestines and abdominal organs are treated with special solutions. Such a radical method of treatment does not always save the patient's life, but there is no other method of eliminating the infected exudate.

Among other things, if a patient is diagnosed with severe ascites, a peritoneovenous shunt is inserted or deperitonization of the abdominal walls is performed. This allows liquid to be removed directly. In addition, surgical interventions can be performed that indirectly contribute to the elimination of ascites. In some cases, measures are required to reduce the pressure in the portal system. For this purpose, a lymphovenous fistula or reduction of splenic blood flow is often done. In addition, intrahepatic shunting can be performed. In rare cases, splenectomy is performed. With the development of ascites against the background of cirrhosis, only liver transplantation can improve the patient's condition and prevent the accumulation of transudate.

Prognosis for abdominal ascites

The accumulation of fluid in the abdomen is a serious complication of any disease. The prognosis of survival depends on the general condition and the primary pathology that provoked the development of the problem. In addition, peritonitis, hepatorenal syndrome, hepatic encephalopathy and bleeding can significantly aggravate the situation. Adverse factors that worsen the prognosis include:

elderly age;
liver cancer;
elevated albumin levels;
decreased glomerular filtration of the kidneys;
diabetes;
hypotension.

In older people with the above pathologies, the prognosis for the development of ascites is unfavorable. In this case, even with targeted therapy, the life expectancy of patients rarely exceeds 6 months, and in the most favorable variant, no more than 2 years.

Ascites is a formidable complication, indicating that the primary disease is difficult.

Currently, new techniques are being actively developed to improve the condition of patients with such a complication, but, as a rule, a good prognosis of survival is observed only in cases where the pathology was detected at an early stage of development.

One of the serious complications arising from various oncological ailments is ascites.

What is ascites, why does it occur and what should people do when faced with a similar problem?

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What

Ascites is a pathological accumulation of water in the peritoneum of a person. Very often this disease accompanies malignant tumors in various tissues and organs:

endometrium;
the gastrointestinal tract;
lungs and bronchi;
mammary and pancreas;
ovaries.

In all these cases, with the exception of ovarian cancer, the appearance of ascites speaks of the third and fourth stages of oncology, when, unfortunately, treatment is already impossible.

With a tumor in the ovaries, fluid can begin to accumulate in the peritoneum already at the first stage of the disease. In this case, the disease responds well to treatment with chemotherapy.

Causes of occurrence

The main reason for the onset of ascites in cancer patients is that when tumor cells settle on the peritoneal tissue, it complicates the drainage of lymph by mechanical means.

By constricting the veins passing through the liver, hydrostatic pressure increases, which leads to the appearance of the disease.

There is also chylous ascites resulting from the development of peritoneal lymphoma. This type of ailment is characterized by the release of lymph and emulsified fats that penetrate into the abdominal cavity and intestines.

Symptoms

With ascites that accompanies oncological diseases, heart failure and a number of other ailments, many patients complain of the following symptoms:

Bloated, enlarged belly. As a result of the constantly increasing amount of fluid in the peritoneum, the patient's weight increases. Difficulty breathing and eating. Heartburn or nausea is common.
Infections. If not treated, the patient may develop peritonitis, often develops cardiac and renal failure... In such cases, doctors' predictions are extremely negative. Patients are prescribed a long course of antibiotic therapy.
The appearance of a hernia (umbilical, inguinal) due to constant pressure inside the peritoneum.
Violation of urine flow.
Shortness of breath even in a calm state, which can occur due to the accumulation of fluid in the lungs.
Swelling of the limbs.
Fast fatiguability.

During the physical examination, the doctor may look for fluid accumulation in the peritoneum.

After that, the patient will be sent for an additional examination (ultrasound, X-ray or CT) to confirm the diagnosis. As a rule, doctors recommend puncture or laparocentesis.

Diagnostics

People with various oncological diseases are always under close medical supervision. Taking into account all the complaints and symptoms of the patient, the doctor can determine the options for the development of the disease.

Various diagnostic methods are used to detect ascites:

Percussion or tapping of the abdomen. In the presence of ascites, the tapping sound will be dull. If the position of the patient's body changes, the dullness of the sound will also shift.
Auscultation or listening. At the same time, a splash of liquid is clearly heard in the peritoneum.
Ultrasound. This procedure allows you to determine the presence and location of the tumor, the amount of fluid, the size of the internal organs. Too much water in the patient's abdominal cavity can interfere with identifying all the subtleties.
Laboratory tests of blood and urine, taking liver samples.
Hepatoscintigraphy makes it possible to determine the size and condition of the liver, to assess the changes in its work.
Doppler ultrasonography shows the state of blood vessels.
Laparocentesis and puncture are the collection of fluid from the peritoneum, followed by laboratory research... Bacteriological sowing of liquid is carried out, the cellular composition and the presence of protein are determined. It should be noted that approximately 1% of patients may have a complication after the procedure.
X-rays give an idea of \u200b\u200bthe condition of the diaphragm and show the presence of water in the abdominal cavity.
MRI makes it possible to determine the exact amount of fluid and its location in the peritoneum.

Based on the amount of fluid available in the cavity, 3 stages of the disease are distinguished:

Transient - the approximate volume is no more than 0.5 liters. The patient in this case complains of bloating.
Moderate - the volume of accumulated water is up to 5 liters. Symptoms of the second stage include: shortness of breath, digestive disorders. If treatment is not started on time, the person may develop peritonitis, heart failure and liver problems.
Resistant - the volume of liquid can reach 20 liters. The patient's condition in this case is assessed as critical.

Treatment

Regardless of the cause, ascites should be treated along with the underlying disease. There are three methods of treatment: symptomatic, conservative and surgical intervention.

Conservative

When initial stage ascites is used conservative therapy. It consists in the normalization of the liver. In the presence of an inflammatory liver parenchyma, drugs are prescribed to relieve inflammation.

To make up for the loss of sodium, which is excreted in large quantities in the urine, patients are prescribed diuretics. To normalize lymphatic outflow and reduce hepatic metabolites, bed rest is prescribed. If the cause of ascites is portal hypertension, then the patient is prescribed hepatoprotectors, the introduction of plasma and albumin.

Symptomatic

In case of ineffectiveness of the conservative treatment, the patient is prescribed the procedure of laparocentosis, which consists in removing fluid from the peritoneum by puncturing its wall and using a special apparatus for sucking water. This procedure is performed under local anesthesia.

The maximum amount of fluid that can be removed with laparocentosis is 5 liters. The procedure is repeated after 3-4 days. It should be noted that each subsequent procedure poses an increasing danger to the patient, which consists in the possibility of damage to the intestinal walls.

Therefore, it is rarely repeated. In the event that the fluid fills the abdominal cavity too quickly, a peritoneal catheter is placed in the patient to prevent the appearance of adhesions that may occur with ascites.

Surgical

In case of recurrence of ascites, the patient is indicated for surgery.

If the patient has repeatedly undergone laparocentosis, he is prescribed a special diet and blood transfusion.

This method consists in joining the veins together - the inferior cavity with the collar. This creates a collateral circulation.

If the patient needs liver transplantation, a course of diuretics is prescribed and an operation is performed. After which, the survival rate for 1 year is 70-75%.

Diet

The main treatment for early stages of ascites is to follow a special diet that creates a negative sodium balance in the patient. For this, the intake of water and salt is as limited as possible.

No more than 1 liter of the total amount of consumed liquid and less than 1 g of table salt is allowed per day. A patient with a diagnosis of ascites is prohibited from eating the following foods:

fat meat;
saturated broths;
canned food and smoked meats;
baking;
spicy and salty;
sweets, with the exception of marshmallows and natural jelly;
millet, legumes;
whole milk;
coffee;
onions, garlic, sorrel.

Remember:patients with ascites are prohibited from alcohol, which contributes to the progression of the disease.

The basis of the diet should be:

vegetables and herbs;
low-fat chicken broth;
boiled fish, rabbit or chicken meat;
egg steam omelet;
cottage cheese;
nuts and dried fruits.

It is important to know: it is forbidden to use salt for cooking. It is advisable to stew everything, steam or bake.

In any case, ascites is a complex and serious disease that requires immediate treatment. But, if we talk about ascites in oncology, then the prognosis becomes even more uncomfortable.

This is due to the fact that the fluid contains a large number of cancer cells, which rapidly spread throughout the body. Therefore, in such cases, the patient's relatives are advised to prepare for the worst.

What is abdominal ascites, see the following video:

In women, fluid inside the abdomen is not always a sign of a dangerous illness. It may appear during ovulation, or it may indicate the development of endometriosis, liver cirrhosis, ischemic disease or ovarian cancer. The correct diagnosis depends on the symptoms and is possible after the examination.

Water in a small pelvis in women

Free water can accumulate in the small pelvis in particular and inside the abdominal cavity in general. In the second case the accumulation of water in the peritoneum is called ascites... It can develop in women and men. In the first case (in the small basin), water appears for exclusively “female” reasons. They can also lead to ascites, but not always.

Ovulation is perhaps the most common cause of small amounts of fluid. In women of reproductive age, it occurs monthly. Breaking, the follicle pours its contents into the abdominal cavity. Such water dissolves on its own without posing a health threat.

In addition, the causes of water inside the abdomen in women can be pathological processes that require urgent treatment:

Symptoms of the presence of fluid in the small pelvis

Fluid accumulation is not a disease, but one of its signs... It cannot be diagnosed only by the presence of free water, there must be other symptoms. The following should alert you:

These reasons indicate gynecological problems.

Free water in the small pelvis can appear for natural reasons, fluid inside the abdominal cavity is a sign of serious diseases

What is ascites?

It is fluid in the abdomen. The reasons for women and men may be the same. Ascites is not a disease, but a sign of a complication of a large number of diseases:

The appearance of ascites indicates that the disease is neglected and requires urgent treatment.

Symptoms of the development of ascites

If one of the problems goes too far, water builds up inside the peritoneum. Then the following symptoms appear:

Any of these symptoms, especially their combination, is a reason for an urgent visit to a doctor.

After prolonged fasting due to a lack of protein in the blood, plasma seeps through the walls of blood vessels, ascites is formed.

The origin of fluid in ascites

The fluid inside the abdomen is filtered blood plasma... With a lack of protein in the blood, stagnation in the vessels, blood plasma sweats or seeps through the walls of the vessels into the abdominal cavity. If one of the listed diseases is at an advanced stage, then the amount of water can reach several liters.

Diagnostics, treatment of ascites, prognosis

An ultrasound study will help to understand what is happening with the body. Of all the methods for diagnosing ascites, it is considered the only reliable one, it will help determine the presence of fluid inside the abdominal cavity and its amount.

Treatment tactics depend on the final diagnosis and the volume of water in the abdomen. If surgery is not needed, general recommendations include a low-salt diet, diuretics, vasodilators, and protein-optimal meals. Medicines according to the diagnosis.

The main function of the intestines is to absorb broken down nutrients and water that enter the human body. In addition, the intestine is responsible for the "transit" of food masses through the gastrointestinal tract and their subsequent evacuation, as well as for the breakdown of fiber (a small part of it) and the synthesis of some vitamins (K and H). Again, all liquid consumed by a person enters the gastrointestinal tract, with subsequent absorption of water in its more distal parts. That is, in any case, the water will be in the intestines - it simply cannot be otherwise. However, it should not accumulate there. In the same way as the accumulation of food masses causes the formation intestinal obstruction, and excessive ingestion of fluid into the gastrointestinal tract becomes an etiological factor in various pathologies.

In no case should ascites (accumulation of free fluid in the abdominal cavity) and accumulation of fluid in the intestine be confused. These are absolutely two different in origin and manifestations of pathology. If the cause of ascites is a chronic pathology of the liver and venous system, which leads to the accumulation of a large amount of fluid in the abdominal cavity and is an extremely unfavorable prognostic sign, then water accumulates in the lumen of the digestive tract for completely different reasons, which will be described below. In the overwhelming majority of cases, this condition will be a consequence of all kinds of processes that are acute in the human body. And the accumulation of fluid in the intestines is not so dangerous as ascites (in terms of the prognosis for recovery and life). At least for the reason that the problem of "flooding" of the intestine is much easier to eliminate than the accumulation of free fluid in the abdominal cavity, which is not an independent pathology, but is associated with a chronic, usually incurable, process.

Causes that lead to excess fluid retention

In this case, it would be more expedient to talk not about the accumulation of liquid in a thick and small intestine, but about its increased entry into the lumen of the intestine from the tissues (by definition, it cannot accumulate, unless, of course, complete obstruction of the lumen of the digestive tract does not occur, which is extremely rare). So, the pathogenetic mechanisms contributing to the development of the pathology under consideration:

Intestinal infections - when pathogens enter the body, they interact with the receptors of the cell wall of enterocytes. This leads to disruption of the adenylate cyclase system. As a result, a large amount of sodium, potassium, magnesium and chlorine ions enter the intestinal lumen. According to the principle of concentration gradient, in order to maintain an adequate level of concentration, electrolytes must pass into the lumen of the intestine and water in order to compensate for the disturbed constancy of the internal environment. What actually happens. This is one of the main mechanisms, due to which there is an excess flow of water into the large intestine and the colon (even with normal intestinal motility in terms of absorption, it will stay there longer than the physiological period).
Increased "flooding" of the intestine due to impaired absorption of certain substances (this pathology is called malabsorption syndrome). Without a doubt, this kind of condition is quite rare, however, it is this reason that leads to the development of the most severe conditions (given that it is chronic). That is, enterocytes do not provide the assimilation of any electrolyte (for example, glucose). This leads to an increase in the concentration of this substance in the intestinal lumen, which, in turn, becomes the cause of the uncontrolled flow of fluid from the tissues and intercellular substance into the intestinal lumen (in other words, massive exudation occurs).
Features of nutrition - when eating a large amount of salty or fried food, just like in the previous version, the body needs to consume large volumes of fluid. Taking into account the fact that the banally received water simply will not have time to be absorbed, the effect will be similar to the situation described in the previous paragraph.
Iatrogenic cause. This refers to the accumulation of fluid in the intestines, provoked by the intake drugs... It happens, by the way, very often. For example - massive therapy with crystalloid solutions with a high concentration of electrolytes. Or the use of special solutions for oral rehydration (oralit, rehydron) - however, it should be noted that in this case there will be a physiological increase in the fluid content in the intestinal lumen.

That is, one can draw from all the information listed above one - the only conclusion: the pathological link that leads to excessive accumulation of fluid in the intestine is the same in all cases. An increase in the concentration of electrolytes (sodium, potassium, chlorine, magnesium, glucose, fructose, galactose, maltose and many others) leads to the fact that there is an excessive flow of fluid into the intestinal lumen - in order to maintain the constancy of the internal environment, a physiological reaction of this kind is realized.

There is, however, an exception to this rule - the so-called "accumulation" of fluid in the intestine due to the fact that patency is impaired due to some process (as a rule, it is oncology). That is, water is retained similarly to food masses, but in this case clinical manifestations this condition is leveled by more serious symptoms of concomitant pathology. In addition, there is a violation of the absorption of water by the cells of the large intestine - but this congenital disease is extremely rare. These are actually all the mechanisms of development of the state under consideration.

How is water accumulation in the intestines manifested?

The most characteristic symptom of this condition is severe diarrhea. This is confirmed by the fact that with all infectious diseases affecting the intestines, there is a violation of the stool. That is, due to the fact that a lot of fluid accumulates in the intestines, the fecal masses change their consistency - this is exactly the mechanism that leads to the development of severe diarrhea. For example, with cholera, feces take on the color of rice water - that is, they become almost colorless.

Again, talking about the constant accumulation of fluid in the lumen of the gastrointestinal tract is somewhat incorrect for the reason that it simply cannot be realized due to the anatomical features of the structure of the digestive system. However, the constant excess of the proper flow of fluid into the human body leads to the development of a number of structural disorders of the intestine and nearby organs:

Due to the fact that the fluid in the lumen constantly exerts pressure on the intestinal wall, a violation of peristaltic movements occurs (contractions of smooth myocytes - they are constantly tense). This is the reason for the formation of a certain vicious circle - an increase in fluid content disrupts peristalsis, which leads to difficulties in the implementation of the evacuation function. This is especially pronounced in the case of a chronic process - that is, with malabsorption, when the liquid is constantly in excess quantities in the intestine, this kind of phenomenon occurs on an ongoing basis, which complicates only the course of the underlying disease;
Compression of nearby organs. Naturally, the intestine, swollen from an excessive amount of fluid, puts pressure on neighboring organs. As a rule, pathological effects are exposed bladder, which manifests itself in increased urination;
Dyspeptic syndrome. In any case, the accumulation of fluid in the human body.

How is this condition diagnosed, and how to distinguish the accumulation of fluid in the intestine from ascites?

In the diagnosis of this process, the assessment of the general state of health is of paramount importance. That is, the person will have a swollen intestine, soreness on palpation, tension will be felt. The onset of symptoms of peritoneal irritation is possible and manifests, but only these signs will not be expressed (that is, false negative). Will definitely need to do ultrasound procedure organs of the abdominal cavity and X-ray with contrast (this study will be relevant only if there is every reason to suspect the occurrence of intestinal obstruction).

In addition, it will be necessary to collect an anamnesis from the patient - given that the accumulation of fluid in the intestine is a manifestation of some primary disease, it cannot arise by itself by definition. That is, having learned what disease struck the patient, it will be easy to guess for what reason he has an excessive flow of fluid into the intestinal lumen. Clarification of the history is a fundamental point in the differential diagnosis between excessive accumulation of fluid in the intestinal lumen and ascites. These are two completely different states that arise when various reasons... If the flow of fluid into the intestines is more conducive to infectious diseases, then ascites occurs due to liver pathology (hepatitis, cirrhosis) - protein metabolism is disturbed, the concentration of albumin in the blood decreases and generalized exudation occurs.

When assessing the patient's objective status, in the event that the abdomen is enlarged and tense, there is every reason to assume the development of ascites. In confirmation of this, there will be a violation of the structure of the venous pattern and an increase in the size of the liver (with cirrhosis of the liver, its decrease will be observed).

That is, from the above information it becomes clear that the differential diagnosis of these two conditions is of fundamental importance. This is determined by completely different approaches to patient management tactics.

What are the main approaches to treating the patient in this case?

Again, the technique for eliminating the increased accumulation of fluid in the intestinal lumen is determined by what pathology caused this process. As already mentioned above, in most cases, infectious diseases become the cause of the phenomenon under consideration. That is, the following therapeutic measures will be needed:

Elimination of the pathogenic agent, due to which this process manifested itself (etiological treatment). Removing the causative factor, it will be possible to note the disappearance of all symptoms after a while. Broad-spectrum antibiotics (cephalosporins, fluoroquinolones) are used to kill bacteria.
Treatment of a patient suffering from intestinal fluid accumulation caused by malabsorption syndrome consists mainly of dietary adjustments. All other components of the treatment have added value.
In the event that the accumulation of fluid in the digestive system is pronounced, treatment will be reduced to the need for therapy of the underlying disease (elimination of the causes of intestinal obstruction, for example). It will be necessary to carry out a surgical intervention in order to eliminate the morphological defect that obstructs the intestinal lumen and makes it difficult to remove feces and leads to fluid retention.
If it is not possible to establish the obvious cause of fluid accumulation, it will be necessary to perform complex tests to confirm the malabsorption syndrome.

Again, anyway, really effective treatment should eliminate the cause of the condition. Otherwise, the treatment will not have the desired effect.

conclusions

The definition of "accumulation of fluid in the intestinal lumen" is somewhat incorrect, since, by definition, fluid does not accumulate there (even with complete obstruction, the intestinal lumen cannot be completely blocked). But an increased flow of water into the lumen of the alimentary canal in certain cases occurs, and often. However, in fairness, it should be noted that an increase in water content in the colon and small intestine is not in itself a life-threatening condition (apart from cholera).

This condition can be diagnosed on the basis of an assessment of the general condition of the patient, palpation of the abdomen. The clinic of acute conditions very rarely simulates the accumulation of fluid in the intestine.

Of great importance in this case is the differential diagnosis of fluid accumulation in the intestine with ascites. In this case, it is necessary to clearly understand that there is a complication of diseases that are completely different in nature and the correct determination of the tactics of patient management is carried out just after the differential diagnosis between these two conditions is carried out.

Treatment of this condition consists in eliminating the primary pathology, which is the immediate cause of its occurrence. It is possible to make sure that the therapeutic measures carried out have had the desired effect on the basis of an assessment of the general condition of the patient.