Ascites

The ascites ( gr ἀσκίτης askítēs ), colloquially known as dropsy, is a pathological (pathological ) fluid accumulation in the peritoneal cavity.

In healthy individuals, there are only very small traces of fluid in the peritoneal cavity. In many diseases, however, can be increased fluid in the peritoneal cavity detected.

Symptoms

Smaller Aszitesmengen are usually asymptomatic. Only large volumes may generate a noticeable swelling of the abdomen, which is usually painless.

Etiology and Pathophysiology

Common to all causes is the passage of fluid from the blood vessels into the abdominal cavity. The pathophysiological mechanisms are thus similar to the edema, tumor seeding or peritonitis lead to the release of inflammatory factors, which can be liquid permeable vessel wall.

Malnutrition and other causes can albumin deficiency ( hypoalbuminemia ) lead to a reduction of the colloid osmotic pressure of the blood and cause the formation of ascites or favor ( " hungry belly" ).

The same is true for emerging congestion of the blood outflow, in right heart failure the inferior vena cava or the portal vein in liver cirrhosis concerning.

With a vessel or organ injury in the abdomen it can to Hämatoperitoneum (blood in the peritoneal cavity ) may occur, which can be regarded as a special form of ascites, but must be distinguished in the differential diagnosis. In particular, the spleen and the liver must then be checked for cracks.

Of malignant ascites occurs when the cause of the ascites is due to a tumor. Triggers can be a massive infestation of the peritoneum with metastases ( peritoneal ) or portal hypertension and hypoalbuminemia due to liver cancer or liver metastases.

Diagnostics

• Physical examination Visible swelling
• Undulationsphänomen: the case of lateral abutment of the abdomen is a wave that can be felt on the other side forms

• Examination of the fluid by color and odor
• Analysis of the liquid in the laboratory microbiology
• Cytodiagnostics
• Clinical Chemistry

Complications

• Gastroesophageal reflux disease, dyspnea, increased intra-abdominal pressure due to Darmwandhernien
• Hydrothorax
• In liver cirrhosis increased risk of variceal bleeding

A dangerous complication of ascites, spontaneous bacterial peritonitis (SBP ): In approximately 15 % of patients with portalem ascites ( ie ascites due to an increase in pressure in the portal vein as in cirrhosis ), there is a migration of intestinal bacteria from the intestine with subsequent peritonitis. The most common pathogens are in this case Escherichia coli ( 50%), gram-positive cocci ( 30%) and Klebsiella (10 %). Most patients have no fever or abdominal pain, diagnostic helping the ascites, in which there are more than 250 granulocytes / ul. The germ proof is often not possible. However, the SBP is connected with a high mortality rate of up to 50 %. Therapy: third generation cephalosporins, then relapse prophylaxis with oral fluoroquinolone.

However, a recent microbiological study rebutted the presumption that the responsible for SBP bacteria are exclusively members of the intestinal flora. In addition, bacteria were detectable before the appearance of the SBP symptoms. The exact mechanisms that lead to colonization of the peritoneum, therefore are largely unclear.

Therapy

Mild cases of ascites can be treated with sodium restriction. Established has the portal ascites and the administration of spironolactone, an aldosterone antagonist. Electrolytes and weight should be checked regularly, as one should draw a liquid balance sheet.

Moderate cases are, eg, furosemide, treated with an additional dose of a loop diuretic. The washout should be gentle, ie no more than 500 grams of weight loss per day, to prevent the emergence of a hepatorenal syndrome.

Severe, intractable gradients can additionally with paracentesis, so the Abpunktion the liquid, with simultaneous albumin transfer and subsequent relapse prophylaxis with diuretics ( drugs to increase the renal excretion ) are treated. In this method, the effusion is punctured and drained through the abdominal wall. Since the ascites usually forms quickly, this method must be repeated necessarily. Although this can be performed by the physician on an outpatient basis. The disadvantage is that at each iteration, the risk of bleeding, bacterial infection of the abdominal cavity and injuries is available. It has been shown that patients due to the pain and discomfort often delay the punctures until the symptoms are unbearable. As an alternative to the continuous punctures laying a thin drain hose ( PleurX ascites) has proven itself in the abdominal cavity lately. The in abdominal part of the silicone tube has a plurality of holes through which the effusion may enter the catheter. Outside the abdominal cavity of the tube runs in the subcutaneous adipose tissue, to prevent bacterial infections. At the end of the hose to a valve, the entry of air and liquid leakage is prevented when there is no active relief by the patient or the nursing staff takes place. The relief of the effusion takes place with a vacuum bottle that is connected through a special valve to the catheter. If the terminals are opened on the drainage bottle, liquid can be drained quickly and actively from the abdominal cavity. Most patients can accomplish even this after a briefing. The catheter can be placed on an outpatient basis with local anesthesia, the draining of the ascites itself is painless. Likewise, a TIPS ( transjugular intrahepatic portosystemic ( stent ) shunt), so be created a connection between the portal vein and the lower hollow vein. It then takes however a nearly unhindered Anstrom degraded by the liver of normal substances in the circulation.

Another treatment option is the transplantation of liver cirrhosis dar.

Malignant ascites is often treated with repeated paracentesis. In addition, shunts and chemotherapy are used, the part directly into the abdominal cavity (intraperitoneal ) may be administered, as well as the approved specifically for the treatment of malignant ascites antibody Catumaxomab.