Ascites

DEFINATION.:
Ascites is defined as collection of excess of fluid within the peritoneal cavity.

MECHANISM-
1. Inflammation of peritoneum-->increased capillary permeability-->transudation of fluid into peritoneal cavity. Eg. Bacterial and T.B  peritonitis,
2. Venous obstruction -->transudation of fluid into peritoneal cavity. Eg. I.V.C  obstruction.
3. Lympathic obstruction -->chylous ascites.
4. Rupture of viscus-->outpouring of blood and cystic fluid -->ascites.
5. Mechanism in liver cirrhosis.
A. Liver failure -->redistribution of blood -->reduced G.F.R  -->salt and water retension. -->Ascites.
B. Failure of liver to metabolise vasopressin -->reduce renal water clearance.
C. Portol hypertension-->raised hydrostatic pressure -->extravasation of fluid from plasma into peritoneal cavity.
D.Hypoalbuminaemia--> reduced oncotic pressure -->extravasation of fluid.
E.Secondary hyperaldosternism-->salt and water retension.

CAUSES :-

TRANSUDATE.
1.cirrhosis and portal hypertension.
2. Congestive cardiac failure. .
3. Nephrotic syodrome.
4. Constrictive pericarditis.
5.Beri beri.
6. I.V.C obstruction.

EXUDATIVE.
1. T.B peritonitis.
2. Malignant peritonitis.
3. Bacterial peritonitis.
4. Pancreatic peritonitis.

MISCELLANEOUS :
1. Meigs syodrome.
2. Chylous ascites.
3.Budd  chairi syodrome.



CLINICAL FEATURE-
SYMPTOMS=
- Abdominal distension.
- bloated feeling in abdomen.
-dyspnoea nd orthopnoea.
- indigestion and heart burns

SIGNS=
-abdomen distension and fullness in flanks.
-skin over abdo stretched and shiny.
- umbilicus may be flat or everted.
-divartication of recti and herni.
-Abdo wall may show distende veins.caput medusae-->veins radiating out with flow away from umbilicus. Prominent veins in flanks with upward flow of blood ->I.V.C obstruction.
-large amount of fluid -->horse shoe shaped dullness. Epigastric and umbilical region remain resonant due to floating intestine.
- shifting dullness if fluid >1000  ml.
-fluid thrill positive in tense ascitis.
- puddle sign can detect as low as 120 ml. Of fluid.

SECONDARY EFFECTS
-Scrotal oedema.
-pleural effusion ,right sided.
-cardiac apex sifted upward due to raised diaphragm.
-Neck veins distended.

INVESTIGATION
1.Ultra sonograph.
2.Diagnostic paracentesis.
3.Lararoscopy.
4.Peritoneal biopsy.

EXAMINATION OF ASCITIC FLUID.
INVESTIGATION
1. Gross appearance.
A. Clear, straw colored -> cirrihosis, congestive cardiac failure.
B. Haemorrhagic.->T.B., malignancy.
C. Cloudy ->bacterial peritonitis.
D. Milky white -> lympathic obstruction.
2. Specific gravity,
transudate <1.016;
exudate >1.016.
3. Protein ,
transudate  <2.5g /dl.
Exudate >2.5g /dl.
4. Glucose->low in malignancy ,tuberculosis.
5. Amylase activity  >1000units/ lit
6.Microscopy,for ziehl neelsen staining.cytological examiniation.
7.Culture.
8.S.A.A.G_1.1g/dl in portal hypertension.And <1.1 g/dl. Other causes.


TREATMENT
Treatment depends on the cause .
1.Tuberculosis peritonitis.
-Anti tuberculosis chemotheraphy.
2. Malignant peritonitis
-repeated paracentesis.
-Intra peritoneal instillation of methotrexate,nitrogen or chloroqvine slows down rate of accumulation.
3.Pancreatic ascites.
-nasogastric station.
-Ascitic tap.
-octretide inhibits pancreatic recreation.
4.Bacterial peritonitis.
-surgical emergencyi
-correction of fluid and electrolyte disturbance.
-broad spectrum antibiotic.
-treat shock.
5.Chylous ascites.
-surgical treatment.
-ascitic fluid tapping.
6.Meigs syndrome
-removal of pelvic tumour.