Ascites ! Read this article

Introduction

Ascites is a medical condition where it is described as the accumulation of abdominal fluid in the peritoneal cavity. Under normal circumstances, there will be a small amount of fluid in the abdomen, which will continue to be produced and absorbed, but when there is an imbalance in the process, the fluid will accumulate.

Pathogenesis / Causation

The following mechanisms lead to ascites:

Increased hydrostatic pressure, which may lead to

1. Cirrhosis
2. Hepatic vein occlusion (Budd-Chiari syndrome)
3. Inferior vena cava obstruction
4. Constrictive pericarditis
5. Congestive heart failure

Decreased colloid osmotic pressure, which may lead to

1. End-stage liver disease with poor protein synthesis
2. Nephrotic syndrome with protein loss
3. Malnutrition
4. Protein-losing enteropathy

Increased permeability of peritoneal capillaries, which may result from

1. Tuberculous peritoneum
2. Bacterial peritonitis
3. Malignant disease of the peritoneum

Leakage of fluid into the peritoneal cavity leads to

1. Bile ascites
2. Pancreatic ascites
3. Chylous ascites
4. Urine ascites

Miscellaneous causes of ascites

1. Myxedema
2. Ovarian disease
3. Chronic hemodialysis

Symptoms

The presence of ascites usually is indicated on physical examination and clinical features, abdominal distension, a fluid wave, or shifting dullness.

The main symptom of ascites is an enlarged abdomen. The clothing may become tight and the belt size may need to be increased. If the amount of fluid is large, it may feel uncomfortable and make the abdomen feel "heavy." Some people may try to adjust the way they stand or walk due to an enlarged abdomen, which may cause posture changes. Weight gain caused by other fluids may lead to decreased mobility. The accumulated fluid may put pressure on the intestines, making the person want to eat less, becoming constipated, or burning in the chest (indigestion). Nausea (sickness) and vomiting (sickness) may also occur. It may increase the pressure in the lungs and sometimes accumulate fluid in the lungs, causing shortness of breath, especially when lying down.

Diagnosis

The presence of ascites can be confirmed by examination, but it can usually be confirmed by an ultrasound scan of the abdomen. This can detect the presence of fluid and provide information about how much fluid there is and other important information about internal organs (especially the liver). 

A blood test and possibly further scans may be required to find out the cause of the ascites. In addition, ascites samples can be collected to find out the cause. This is done with small needles and usually causes only mild discomfort.

Investigation

1. Paracentesis can be performed with or without guidance by ultrasonography, the ascetic fluid should be analyzed.
2. Abdominal ultrasonography can reliably detect a small amount of fluid.
3. Total protein content greater than 2.5 g/dl is diagnostic of exudative ascites, which usually is seen in tumors, infections, and myxedema.
4. Albumin and total protein count, serum ascites albumin gradient (SAAG) is very helpful in finding out whether ascites are due to portal hypertension or not, SAAG> 1.1 gm/dl suggests portal hypertension.
5. Amylase concentration is elevated in pancreatic ascites.
6. Cytology frequently is positive in malignancy.
7. White cell count greater than 350 / mm is suggestive of infection.
8. Red corpuscles count greater than 50,000 / mm denotes hemorrhagic ascites.
9. Gram staining and culture document bacterial infection.
10. Laparoscopy is indicated in cases of suspected peritoneal T.B or neoplasms.

Treatment

1. Depends on the underlying cause.
2. Transudative ascites may be treated by bed rest, sodium restriction, and careful use of medicines for diuresis.
3. The process of paracentesis of up to 1 L of fluid may provide relief of acute respiratory embarrassment secondary to tense ascites, but removal or more than 1 L at a time may lead to hypovolemia and shock as fluid reaccumulates in the peritoneal cavity.
4. A Le Veen shunt may be used for intractable or malignant ascites but causes a high risk for the development of infection and disseminated intravascular coagulation.
5. Some people may suffer from "refractory ascites," which means that there is no response to a low-salt diet or medication, the medication has side effects, or the need for frequent drainage (puncture). 
6. Treatment options in this situation include radiological examination (X-ray guidance) of the liver blood vessels (known as "trans-jugular intrahepatic portosystemic shunt" or "TIPSS"), or rarely a liver transplant.

Ascetic fluid characteristics in various disease states

Condition	Gross Appearance	Specific Gravity	Protein g/dl	Cell count, RBC >10000/ml	WBC per ml
Cirrhosis	Straw-colored or bile-stained	<1.016(95%)	<25(95%)	1%	<250, predominantly mesothelial
Neoplasm	Straw-colored, hemorrhagic, mucinous, or chylous	Variable > 1.016 (45%)	>25(75%)	20%	>1000 (50%) variable cells types
Tuberculous	Clear, turbid, hemorrhagic, chylous	Variable >1.016 (50%)	>25(50%)	7%	>1000(70%), usually >70% lymphocytes
Pyogenic peritonitis	Turbid or purulent	If purulent, >1.016	If purulent, >20.5	Unusual	Predominantly polymorph nuclear leukocytes
Congestive heart failure	Straw colored	Variable <1.016(60%)	Variable 15-53	10%	<1000(90%), usually mesothelial, mononuclear
Nephrosis	Straw colored or chylous	<1.016	<25(100%)	Unusual	<250, mesothelial, mononuclear
Pancreatic ascites	Turbid, hemorrhagic, or chylous	Variable, often >1.016	Variable often >25	Variable, maybe bold stained	Variable

Homeopathic treatment

For Peritonitis: Aconite Nap, Bryonia alba is the good medicines

Tubercular: Tuberculinum, Lycopodium are good medicines

Ascites: Apis Mel, Cinchona and Apocynum Can good medicines