Ascites

It can be defined as the chronic accumulation of serous fluid in the peritoneal cavity.

DIAGNOSIS:

Ascites is manifested by a rapid increase in volume of the abdomen (a few days).

Review:

On physical examination, there was an aspect of bloated abdomen with a strained abdominal wall and an unfolding of the navel, sometimes even an umbilical hernia.

Percussion dullness flank found in the patient supine, this dullness moves with position changes. The percussion also to confirm the fluid nature of the “big belly” if the vibrations are transmitted from one side to the other.

In fact these signs are necessary in case of low abundance ascites. Clinical diagnosis is usually easy when it is large.

Palpation search hepatomegaly, splenomegaly, peritoneal nodules, a peri-umbilical nodule (Sister Mary Joseph nodule). Sometimes the discovery of organomegaly is difficult to ascites. One can search the sign of ice.

We must look for signs of portal hypertension (venous collateral circulation Periumbilical, splenomegaly), hepatocellular insufficiency (spider nevi in the territory upper cellar, palmar erythrose, gynecomastia, signs of encephalitis …).

Peripheral lymphadenopathy is also sought.

It goes without saying that the discovery of ascites must look for leg edema, pleural effusion, hypotension, signs of right ventricular failure …

The presence of an associated stop transit must fear a neoplastic or infectious ascites.

It should also assess the recent weight gain.

Exploration:

The exploration of ascites is hospitable. It requires the realization of a puncture for diagnostic or sometimes referred evacuative. The puncture is usually done in the left iliac and analysis of the liquid tank provides good diagnostic orientation.

Commonly divided into the transudate (proteins <25 g / L) and exudate (protein> 25 g / L).

This distinction is sometimes faulted, some ascites infections keeping a low protein levels.

Cellularity is useful for diagnostic orientation.

An important element for the understanding of the mechanism is the measurement of albumin gradient.

This is the difference in serum and ascites of albumin. If this gradient is greater than 11 g / L, then we can be virtually certain of the presence of portal hypertension.

Imaging is useful to affirm a scarce ascites or compartmentalized, but especially for the etiological diagnosis (ultrasound and scanner).

They seek signs of cirrhosis, portal hypertension, thrombosis of the hepatic vessels, abdominal lymph nodes, peritoneal nodules, tumor mass.

ETIOLOGY:

Hepatic cirrhosis:

This is the most common cause of ascites and whatever the cause of cirrhosis.

Ascites is usually a clear, low protein (<25 g / L) but with a high albumin gradient (> 11 g / L). There are few cells in smears. The presence of cellularity than 250 / mm3 with a predominance of neutrophils must fear an infection of ascites.

Alcohol is the leading cause of cirrhosis in France, followed by viral hepatitis B and C.

The treatment of ascites following several areas: monitoring the progress of cirrhosis by acting on the underlying disease, treatment of fluid overload and infection prevention.

The treatment of fluid overload is based on diuretics including spironolactone first line associated with a low-salt diet (2 g / d). The loop diuretics can be associated if this proves insufficient (furosemide).

If, despite these measures, ascites becomes refractory, you must use the iterative punctures that can easily be done by day hospitalization.

Primary prevention of ascites infection has mostly been validated in alcoholic cirrhosis, it is justified when the protein level is less than 10 g / L, is favored norfloxacin (Noroxine®) 400 mg / day.

Portal hypertension:

Apart from cirrhosis, diseases responsible for portal hypertension are etiologies of ascites: portal thrombosis, thrombosis of the hepatic veins (Budd-Chiari syndrome), especially in its chronic form, heart failure, veno-occlusive disease liver.

The ascitic fluid is a transudate albumin with a gradient greater than 11 g / L.

The treatment is that of the etiology and treatment of fluid overload.

Neoplastic ascites:

This is called peritoneal carcinomatosis. The clinical picture is quite noisy with a poor general state of frequent bowel dysfunction (occlusion or sub-occlusion). Palpation may find localized or diffuse peritoneal nodules.

The malignant ascites generally occurs in patients with a known and advanced neoplasia (colon cancer, pancreas, lung, stomach, pleural mesothelioma, breast and ovary).

But it is also a fashion classic revelation ovarian cancer and peritoneal mesothelioma.

Neoplastic ascites also occur (more rarely) in the high-grade lymphomas.

The ascitic fluid is an exudate (protein> 25 g / L) with albumin gradient less than 11 g / L. However, this gradient can be positive in portal hypertension situations associated with liver metastases.

Cellularity is important often with higher rates to 500 / mm3. Neoplastic cells are often found, their absence does not exclude the diagnosis in a meaningful context.

Sometimes it is chylous ascites.

If the original tumor is not known, it is necessary to perform a whole body scanner and if required high and low digestive endoscopy, the determination of CA 125 in a woman is helpful and seems justified in this context.

The peritoneal biopsies are required if no primitive is highlighted.

If ovarian cancer is suspected, it is essential to quickly perform an exploratory laparoscopy for diagnosis and staging(first look).

The treatment is that the tumor involved, diuretics and salt restriction may help if portal hypertension associated with it (albumin gradient> 11 g / L).

Corticosteroids are an adjunct therapy whose effectiveness fades after a few days.

Chronic Pancreatitis:

Ascites may appear in complicated chronic pancreatitis pancreatic pseudocysts.

It results from a communication between pseudocyst and peritoneum.

Alcoholism is the main etiology of chronic pancreatitis in France, look for an associated cirrhosis.

The ascites fluid has the distinction of being rich in cells and amylase (which affirms the diagnosis) with often much higher than the serum levels.

Imaging should seek a rupture of pancreatic duct or communication between pseudocyst and peritoneal cavity.

The ideal treatment is surgical, knowing that the operative risk is very high in this field.

Peritoneal Tuberculosis:

She is responsible for a painful ascites with general symptoms (fever, weight loss), abdominal pain and bowel dysfunction fickle.

It must be considered in patients oldest known tuberculosis, immunosuppression (HIV, immunosuppression), advanced age, or concept of living in highly endemic countries or in prison.

Diagnosis is often difficult to confirm.

The ascites fluid is rich in exudate cells (often> 500 / mm3) with a predominance of lymphocytes (> 70%).

AFB (acid fast bacilli resistant) is rarely positive on direct examination (3%), culture is positive in 20-60% of cases, with a delay of several weeks.

Search by polymerase chain reaction must be carried out, but its true value to be determined.

A test that is useful in this situation, the dosage in the ascitic fluid of adenosine deaminase. A value greater than 33 U / L (50 U / L for some authors) is predictive of 98% of peritoneal tuberculosis.

The diagnostic reference still remains peritoneal biopsy (by laparoscopy) with pathological examination found that granulomas with caseous necrosis.

The treatment is that of tuberculosis according to conventional patterns of 6 or 9 months. But some teams tend to prolong the treatment for 12 to 18 months in total.

Nutritional support is often necessary in cachectic patients.

If initial occlusive events, a short corticosteroid therapy can be offered in combination with antibiotics, this is a very risky treatment that must be done in a specialized environment.

Pseudomixome peritoneal:

Also known as gelatinous disease in the abdomen, it is developed a tumor pathology most often at the expense of the projection or the ovary. Rare disease with an annual incidence of 1/106 people and affects slightly more often women.

The main clinical expression is composed of a gelatinous ascites fluid. Other clinical signs include pain or bowel obstruction.

Considering pathology, it is not strictly speaking a cancerous disease.

However it has a tendency to recur and develop metastases.

Treatment is surgical resection of the tumor associated with hyperthermic intraperitoneal chemotherapy.

Meigs syndrome:

It is also a rare entity.

The Meigs syndrome in his initial description associated the triad of benign ovarian tumor, ascites and pleural effusion (often right).

This clinical picture was described with other benign pelvic or metastases of other malignancies ovaries; it is called pseudo-Meigs syndrome.

The ascites fluid is usually a transudate. The mechanism is unclear.

The effusion should disappear after tumor resection.

Heart failure:

This is a rare cause of ascites mostly through portal hypertension; Ascites can be isolated or be part of an array of hydrops.

Myxedema:

In principle, these historical forms, ascites has the distinction of having an albumin gradient greater than 11 g / L.

Another pathology “endocrine” may give ascites is ovarian hyperstimulation syndrome in women receiving treatment for ovulation.

Chylous ascites:

It is not strictly speaking an etiology of ascites, however it deserves to be distinguished as the etiologic is special.

It is the consequence of the accumulation of lymph fluid in the peritoneal cavity. The commonly accepted mechanism is an obstacle on the lymphatic network.

Ascites has a whitish appearance with a triglyceride concentration exceed 200 mg / dL.

The protein content may vary depending on the etiology, generally above 25 g / L.

The causes of chylous ascites in rich countries are primarily abdominal tumors, mainly lymphomas, this in front of cirrhosis.

In developing countries, it is above all tuberculosis and filariasis.

Other causes are iatrogenic (major abdominal surgery or vascular, abdominal radiotherapy), rare (sarcoidosis, Whipple’s disease, pancreatitis, pericarditis constrictive).

Congenital lymphatic diseases (yellow nail syndrome …) generally appear sooner in children.

Treatment is primarily that of the etiology.

Unfortunately, it is more difficult in the postoperative ascites or postradique. In these cases we can provide a high protein diet, low in fat favoring medium chain fatty acids. Indeed these fatty acids are directly absorbed through the portal system to the liver, unlike the long chain fatty acids implement chylomicrons.

In some situations somatostatin associated with parenteral nutrition has proven effective.

The surgical solution is to be avoided as far as possible and should be reserved for medical treatment failures.