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Ascites

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 ICD9        = 789.5|

}} In medicine(gastroenterology), ascites is an accumulation of fluid in the peritoneal cavity. Although unpleasant, it is not intrinsically harmful. Nevertheless, its causes and complications are both significant medical problems.

Inhaltsverzeichnis

1 Signs and symptoms
2 Diagnosis
3 Classification
4 Pathophysiology
5 Causes
6 Treatment
7 Cultural significance
8 Source
9 See also

Signs and symptoms

Mild ascites is hard to notice, but severe ascites leads to abdominal distension. In patients with ascites, a doctor will attempt to identify causes, such as a history of liver disease, other signs of portal hypertensionor signs of tuberculosisor nephrotic syndrome.

A proportion of chronic ascites patients also develop hepatic hydrothrorax, e.g. unilateral pleural effusion(mainly right-sided) due to liver disease, and many have para-umbilical herniations of the abdominal wall.

Diagnosis

Several blood tests are commonly performed for ascites, including full blood count, electrolytesand renal function, liver enzymes, and glucose. If the cause is not apparent, serologyfor virusesknown to cause hepatitisand ferritinmay contribute to the analysis.

Ultrasoundinvestigation with doppler studies can be an important help, and may identify such problems as Budd-Chiari syndrome, portal vein thrombosisand cirrhosis. Additionally, the sonographer can make an estimation of the amount of ascitic fluid.

Studies of the fluid removed by paracentesis (see below) may aid in the diagnosis. It can also help diagnose spontaneous bacterial peritonitis, a serious complication of ascites.

Classification

Ascites exists in three grades:

Grade 1: mild, only visible on ultrasound
Grade 2: detectable with flank bulging and shifting dullness on physical examination
Grade 3: directly visible, confirmed with fluid thrill (or fluid wave)

Pathophysiology

Ascitic fluid can accumulate as a transudateor an exudate. Amounts of up to 25 litres are fully possible.

Roughly, transudates are a result of increased pressure on the portal vein(>8 mmHg), e.g. due to cirrhosis, while exudates are actively secreted fluid due to inflammationor malignancy. As a result, exudates are high in protein, high in lactate dehydrogenase, have a low pH(<7.30), a low glucoselevel, and more white blood cells. Transudates have low protein (<30g/L), low LDH, high pH, normal glucose, and fewer than 1 white cell per 1000 mm³. Clinically, the most useful measure is the difference between ascitic and serum albuminconcentrations. A difference of less than 1 mg/dl implies an exudate.

Regardless of the cause, sequestration of fluid within the abdomen leads to additional fluid retentionby the kidneys due to stimulatory effect on blood pressure hormones, notably aldosterone. The sympathetic nervous systemis also activated, and reninproduction is increased due to decreased perfusion of the kidney. Extreme disruption of the renal blood flow can lead to the feared hepatorenal syndrome.

Other complications of ascites include spontaneous bacterial peritonitis(SBP), due to decreased antibacterial factors in the ascitic fluid such as complement. Many acutely ill ascitic patients have SBP and require antibiotictreatment.

If portal hypertensionis the cause, complications can be fulminant, such as bleeding esophageal varices.

Causes

Causes for transsudates are:

Cirrhosis - 81%
- alcoholic - 65%
- viral - 10%
- cryptogenic - 6%
Heart failure- 3%
Budd-Chiari syndrome or veno-occlusive disease
Constrictive pericarditis

Exudates are caused by:

Cancer(primary and metastasis) - 10%
Tuberculosis- 2%
Pancreatitis- 1%

Treatment

Primary treatment for ascites is with diuretics, which is safer than ascitic drainage. Spironolactone, in particular, appears to be the diuretic of choice. Furosemide, another diuretic agent, is often added. If it remains refractory on diuretics, frequent paracentesis may be necessary. The ascites thus gained should be analysed in the medical laboratoryfor the abovementioned causes. As last resort, a TIPS (transjugular intrahepatic portosystemic shunt) procedure can be performed by radiologists. Liver transplantation is done in selected patients.

Cultural significance

It has been suggested that ascites was seen as a punishment especially for oath-breakers among the Proto-Indo-Europeans(Oettinger, StBoT22:71). This proposal builds on the Hittite military oathas well as various Vedichymns (RV7.89, AVS4.16.7). A similar curse dates to the Kassitedynasty (12th century BC), threatening oath-breakers: "May Marduk, king of heaven and earth, fill his body with dropsy, which has a grip that can never be loosened". Comparable is also Numeri5:11ff.

Source

Oxford textbook of medicine
Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med2004;350:1646-54. PMID 15084697.