Ascites

Introduction Ascites refers to the excessive accumulation of free fluid in the abdominal cavity. Under normal conditions, there are about 50 ml of liquid in the abdominal cavity, which lubricates the intestines. In any pathological condition, the amount of intra-abdominal fluid increased by more than 200 ml is called ascites. Ascites is a clinical manifestation of many diseases. There are many causes of ascites. The more common ones are heart disease, liver disease, kidney disease, peritoneal disease, nutritional disorders, malignant tumors, and connective tissue diseases. In the past, the diagnosis of ascites mainly relied on abdominal percussion, and it was diagnosed as ascites with mobile dullness.

Cause

Cause

Ascites occurs due to systemic or local factors causing fluid to penetrate or leak into the abdominal cavity from the blood vessels and lymphatic vessels. Hypoproteinemia, sodium and water retention, decreased inactivation of vasopressin and aldosterone, portal hypertension, hepatic vein occlusion, peritoneal inflammation and malignant tumors are all important factors in causing ascites.

Ascites-related symptoms: When the patient has a small amount of ascites (300-500 ml (ml)), it can be easily noticed without obvious discomfort. When there is moderate amount of ascites (500-3000 mL), it will consciously swell, showing a swollen abdominal shape, physical examination. There may be mobility dullness, and when there is a large amount of ascites (3000mL or more), it may manifest as difficulty in breathing and edema of lower limbs. Ascites caused by different diseases often show different accompanying symptoms, such as fever, jaundice, anemia, liver and spleen enlargement, heart failure and other symptoms and signs.

an examination

Related inspection

Ascites examination for abdominal puncture

First, medical history

Ascites caused by different causes have a history of each primary disease. For example, ascites caused by heart disease often has labor difficulty breathing, lower extremity edema after mental activity, and high pillow or semi-sitting position at night. Past medical history can often help diagnose. Ascites caused by liver disease, history of hepatitis or chronic liver disease.

Second, physical examination

The physical examination of ascites often has signs of primary disease in addition to mobile voiced sounds. Ascites caused by heart disease can be seen in the hair group, peripheral edema, jugular vein engorgement, heart enlargement J anterior region tremor, hepatosplenomegaly, arrhythmia J heart valve murmur and other signs. Liver diseases often have dull or sallow luster, yellow scabs on the skin sclera, and may have spider sputum or liver palm, abdominal varicose veins, hepatosplenomegaly and other signs on the face, neck or chest. The ascites caused by kidney disease may have signs such as pale complexion and edema around. Face flushing, fever, abdominal tenderness, and the flexibility of the abdominal wall may consider tuberculous peritonitis. The patient has weight loss, cachexia, swollen lymph nodes or a mass in the abdomen.

Third, laboratory inspection

Laboratory tests are often an important means of finding the cause. Impaired liver function, hypoproteinemia may suggest cirrhosis, massive proteinuria, elevated blood urea nitrogen and muscle metabolism suggest impaired renal function, and immunological examination is also important for the diagnosis of liver and kidney diseases. The nature of ascites and the cause of the identification of ascites can be determined by examination of the peritoneal puncture.

(1) General inspection

1, appearance

The leakage liquid is mostly pale yellow, thin and transparent, and the exudate can be colored or turbid. The ascites of different causes may have different appearances, such as purulent infection is yellow purulent or pus blood; Pseudomonas aeruginosa infection is green in the ascites; yellow jaundice is yellow; bloody ascites is seen in acute tuberculous peritonitis, malignant tumor; chyle ascites is milky white Self-coagulation, because it is a non-inflammatory product, it is still a leak.

2, relative density

The relative density of the leakage liquid is more than 1.018; the relative density of the exudate is more than 1.018.

3, clot formation

The exudate contains fibrinogen and tissue, and the thrombin released by cell destruction, so it is easy to coagulate into pieces or flocs.

(2) Biochemical examination

1. Protein qualitative test: The leakage liquid is negative and the exudate is positive. Quantitative, the leakage is less than 0.25g / L; the exudate is greater than 0.25g / L.

2. The amylase of pancreatic ascites is elevated.

3, bacteriological and histocytological examination of ascites after centrifugation, smear staining can be found in bacteria, acid-fast staining can be found in tuberculosis, if necessary, bacterial culture or animal inoculation. Tumor cells can be examined in ascites, which is necessary for the diagnosis of abdominal tumors. Its sensitivity and specificity can reach 90%.

Fourth, equipment inspection

1. Ultrasound and oral examination can not only show a small amount of ascites, but also the size of the liver, the smoothness of the liver capsule, the intrahepatic space-occupying lesions, the size of the heart, the structure of the heart, the flow of the human heart and the outflow tract, and blood. Flow condition, size, shape, structure, etc. of the kidney.

2. ECG examination can detect changes in heart rate and blood supply to the heart.

Differential diagnosis

Differential diagnosis

1, refractory ascites: also known as intractable ascites. That is, after applying strict sodium, water control and full use of diuretics, after a certain period of time, there is no obvious effect, called refractory ascites. The clinical manifestations are as follows: 1 hospitalized for more than 6 weeks, after strict medical treatment, although the edema has been alleviated, there is still obvious ascites. 2 renal dysfunction, plasma intoxication> 2.4mg%, myocardial clearance rate.

2, cirrhosis ascites: commonly known as liver ascites. Normal people have a small amount of free ascites in the abdominal cavity, usually about 50 ml, which plays a role in maintaining the lubrication between organs. When there is too much free liquid in the abdominal cavity, it is called ascites. Cirrhosis ascites is a chronic liver disease. From massive, nodular, diffuse hepatic changes, necrosis, regeneration, regeneration, necrosis, promote tissue fibrosis and scar contraction, resulting in liver hardening, forming cirrhosis. Liver cirrhosis caused by portal hypertension, resulting in splenomegaly, protein fluid leaking from the absorption of protein and vitamins, formed ascites.

3, bloody ascites: rupture of organs in the abdominal cavity, malignant tumors in the abdominal cavity may cause bloody ascites. Among them, organ rupture is common in liver rupture, spleen rupture, uterine out-of-pregnancy leading to tubal rupture, hemorrhagic necrotizing pancreatitis

4. Non-blood ascites: Free fluid that accumulates in the abdominal cavity. Normal people can have a small amount of liquid in the abdominal cavity to lubricate the internal organs. Ascites can be caused by diseases such as heart disease, liver disease, kidney disease, tuberculosis, malignant tumors, etc. It is a common clinical sign. According to its nature, it can be divided into leakage liquid or exudate; non-blood ascites can be divided into serous or chyle according to its appearance. Asking a patient about a medical history can provide important clues to the diagnosis. A detailed physical examination can provide a basis for diagnosis. Conventional abdominal puncture, ascites extraction for laboratory tests can be determined as exudate or leakage, visual inspection can be determined to be serous, bloody, purulent or chyle. Ultrasound examination may suggest a small amount of ascites or intra-abdominal mass. X-ray, radionuclide scanning, angiography, CT, MRI, etc., have a greater diagnostic value for diseases that cause ascites. Ascites must be differentiated from ovarian cysts.

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