Ascites or astsga means the presence of abnormal fluid which accumulated inside the abdominal cavity or in the peritoneal cavity called ascitic fluid
Ascites is not a disease but it is a sign of many diseases which can causes it such as liver cirrhosis which most common causes of ascites

What are the causes of ascites

There are many causes of ascites such as
  • Liver cirrhosis
  • Nephrotic syndrome
  • Congestive heart failure
  • Malignancy or cancer
  •  Tuberculosis peritonitis
  • Acute pancreatitis
  • Nutritional defieicncy
  • Constrictive pericarditis
  • Ovarian disease like Meig,s syndrome
  • Protein loosing enteropathy such as ulcerative colitis grohn,s disease
  • Lymphatic obstruction as in lymphoma causes chylous ascites
  • Myxoedema
  • Chronic peritoneal dialysis
Symptoms and signs of ascites
What patient complains or feels
  • Small amount of ascites may be asymptomatic and patient not complaining
  • Increased amount of ascites patient complaining from abdominal discomforts abdominal distension and sense of fullness
  • Large amount of ascites the patient may complaining from respiratory distress as dyspnea because ascites compress the diaphragm
  • Anorexia pain in abdominal flanks
  • Symptoms and signs of the associated disease such as jaundice esophageal varices bleeding in case of liver cirrhosis
    The fluid of ascites may take the following nature in specific causes
  • Transudate ascites which has the following criteria its specific gravity less than 1017 protein content less than 2.5 gm|dl protein ascites |serum ratio less than .5 lactic dehydrogenase less than 200 IU|L such as in liver cirrhosis congestive heart failure nephrotic syndrome
  • Exudate ascites or turbid ascites which has the following criteria specific gravity more than 1017 protein content ,ore than 2.5 gm|dl protein ascites| serum ratio more than .5  lactic dehydrogenase more than 200 IU|L such as in bacterial peritonitis or infection tumors and myxoedema
  • Chylous ascites which containing lymphatic fluid also called milky ascites due to lymphatic duct disruption as in lymphoma or trauma
  • Bile ascites such as ruptured gall bladder
  • urine ascites as in ruptured urinary bladder
  • sero-sangianous or meat like or bloody ascites such as in malignancy
  • Hemorrhagic ascites such as trauma to abdomen malignancy acute hemorrhagic panctreatitis disrupted ectopic pregnancy
  • Pancreatic ascites such as acute or chronic pancreatitis which common causes of it alcohol or trauma to the pancreas
How ascites is formed or pathogenesis of ascites

There are several factors which contributed to form ascites such as

In case liver cirrhosis which account for most common causes of ascites about 85%  it is result from
  • Portal hypertension which means increased pressure in the portal vein or liver blood flow which lead to increased hepatic or liver and splanchnic lymph production and transudated fluid which lead to increased hydrostatic pressure
  • Liver cirrhosis causes hypoalbuminaemia and hypoproteinaemia normally the albumin formed by the liver in case of liver cirrhosis liver fail to form it  this lead to decreased colloid osmotic pressure
  • Impaired renal sodium and water excretion secondary to hyperaldosteronsim and increased levels of antidiuretic hormone
  • These factors also causes edema in the lower legs pleural effusion or fluid accumulation at any part of the body like stomach caused gastric congestion and anorexia
Others contributing factors in formation of ascites
  • Increased hydrostatic pressure such as hepatic veins occlusion or thrombosis from portal hypertension (Budd- Chiari Syndrome) constrictive pericarditis tense pericardial effusion congestive heart failure
  • Decreased colloid osmotic pressure such as nephrotic syndrome with protein loos malnutrition protein loosing entropathy
  • Increased permeability of peritoneal capillaries such as tuberculosis (TB) peritonitis bacterial peritonitis malignant disease of the peritoneumn cancer colon cancer ovary cancer stomach etc
  •    Fluid retention such as end stage of renal failure and heart failure due to accumulation of the fluid inside the body and inability to excreted it
What are differential diagnosis of ascitis
Ascites should be differentiated from other causes of abdominal distension such as
  • Obese patient
  • Intestinal or colonic distension by gases
  • Large abdominal tumors
  • Large abdominal cysts like huge ovarian cysts
  • Large intraabdominal fat deposition in the mesentery of the intestine
  • Pregnant women
 Investigations of ascites
Liver function test
The most common causes of ascites liver cirrhosis  this test showing serum bilirubin level which may increased SGOT and  SPGT liver enzymes are raised plasma protein such as albumin decreased
Prothrombin time become prolonged
In case of acute or chronic hepatitis showing hepatitis B and C virus markers
Complete blood count
showing leucocytosis in case of infection increased white blood cells
Anemia decreased red blood cells
Thrombocytopenia decreased platelets count may lead to easy bleeding tendency
Complete urine analysis
Protein or albumin in urine as in case of nephrotic syndrome or renal failure
Amlyase enzyme concentration
Smear is prepared from the ascitic fluid and stained by special stain and examined for malignant cells it common positive in case of malignant ascites
Cytological examination of ascitic fluid
Aspiration of the ascitic fluid usually 100-200 cc  from the intraabdominal cavity and send for cytology may showing that
marked increased in the white blood cells suggestive infection if the most cells are polymorphonuclear
Mon nuclear cells predominate suspected tuberculosis or fungi infection
Marked increased in red blood cell count may indicated either malignancy or tuberculosis or trauma
 Appearance of the fluid or its colour

Clear straw coloured is common seen in liver cirrhosis and transudate ascites bloody fluid suggests malignancy or tuberculosis peritonitis  turbid fluid indicates infection milky fluid ( chylous ascites ) is common due to lymphatic causes also triglycerides elevated in chylous ascites

Gram staining and culture
For diagnosis of bacterial infection
Abdominal ultrasound
Showing ascitic fluid liver pathology tumors
CT scanning of the abdomen
As abdominal ultrasound with specific indications according to disease causing ascites
MRI scanning of the abdomen
As CT scanning
Plain X rays
On the chest may show tubercles in case of tuberculosis or associated pleural effusion or cardiac enlargement
On the abdomen may showing calcification in the mesentric or para aortic lymph nodes
For suspected  heart causes of ascites
Complications of ascites
Most important complications of ascites are
Infection which consider major problems these due to invasion of the peritoneal ascites by the normal intestinal flora or bacteria which occurs spontaneously and so called spontaneous bacterial peritonitis in the form of fever abdominal pain in this case examination of ascitic fluid revealed high specific gravity high protein concentration  and polymorphic leucocytosis
Hepatorenal syndrome which manifested by slow onset of oliguria decreased urine amount during micturation may decreased daily to 100-150 ml but not lead to anuria  what are the criteria for diagnosis of hepatorenal syndrome
  The criteria of hepatorenal syndrome are
  • Liver disease with liver failure and portal hypertension
  • Low glomerular filtration rate creatinine less than 1.5 mg|dl
  • Urine volume less than 500 ml|day
  • Urine sodium less than 10 mEq|l
  • Urine osmolarity more than plasma osmolarity
  • No significant abnormalities of urinary sediment
  • No improvement in renal function following diuretic withdrawal and volume expansion
Treatment of ascites
This depend on the underlying causes see here for treatment of ascites

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