What Is Refractory Ascites?

Ascites refers to the excessive accumulation of free fluid in the abdominal cavity. It is a sign, not a disease. In any pathological state, the amount of fluid in the abdominal cavity exceeds 200 ml is called ascites. There are many causes of ascites. The more common are cardiovascular disease, liver disease, peritoneal disease, kidney disease, nutritional disorders, malignant tumor peritoneal metastasis, ovarian tumors, and connective tissue diseases. Quantitative diagnosis of ascites is based on abdominal percussion, except for imaging examination: when ascites reaches 500ml, it can be confirmed by elbow and knee percussion; ascites above 1000ml can cause mobile dullness, and when there is a large amount of ascites, both sides of the flank bulge like frog belly , Examination may have liquid wave tremor; a small amount of ascites need to be detected by ultrasound.

Basic Information

English name

ascites

Visiting department

Gastroenterology

Common locations

Abdominal cavity

Common causes

Cardiovascular disease, liver disease, peritoneal disease, kidney disease, dystrophy, malignant tumor peritoneal metastasis, ovarian tumor, connective tissue disease, etc.

Causes of ascites and common diseases

Ascites can be caused by many causes, involving multiple organs and many diseases. More than 80% of these diseases are due to cirrhosis, followed by peritoneal inflammation and tumors or metastatic cancer of the peritoneum itself. In addition, there are other rare causes.

Liver disease

Cirrhosis, fulminant liver failure, primary liver cancer.

Cardiovascular disease

Chronic congestive right heart failure, pericarditis (exudative, constrictive), myocardial disease (congestive, restrictive), Keshan disease, Budd-Chiari syndrome [hepatic vein and / or inferior vena cava Obstruction], hepatic venous occlusive disease, portal vein occlusion (portal cavernous degeneration, portal vein thrombosis, portal pressure obstruction)

3. Peritoneal malignancy

Primary: Mesothelioma, Secondary: Peritoneal metastasis.

4. infection

Tuberculous peritonitis, Fitz-Hugh-Curtis syndrome (hepatic envelope inflammatory disease secondary to pelvic infection), Neisseria gonorrhoeae or Chlamydia trachomatis perihepatitis with perhepatic fibrous exudation, HIV infection Patient with infectious peritonitis.

5. Renal

Chronic nephritis nephropathy, nephrotic syndrome, ascites in patients with hemodialysis.

6. Malnutrition.

7. Endocrine

Myxedema, Meigs'syndrome, goiter-like ovarian tumor, ovarian stimulation syndrome.

8. Connective tissue disease

Systemic lupus erythematosus.

9. Other

Pancreatic, bile, urine.

10. Mixed.

Differential diagnosis of ascites

Ascites must be distinguished from ovarian cysts.

Giant ovarian cyst

When the ovarian cyst is in the supine position, the abdomen bulges forward more obviously, shifting slightly upward, and more drum sounds are present on both sides of the abdomen. The dullness of the ovarian cyst is not mobile. Tonometer test: If it is an ovarian cyst, the pulsation of the abdominal aorta can be transmitted to the hard ruler through the cyst. If it is ascites, the hard ruler does not have this beat. Vaginal and ultrasound examinations are helpful in identifying.

2. Identification of benign and malignant ascites

There are many differentiating indicators of benign and malignant ascites, mainly including ascites cytology, biochemistry, immunology and imaging, but they are all non-specific indicators. In order to reduce and avoid misjudgments, comprehensive analysis of clinical data and joint testing should be combined, and it should not be overly dependent on an indicator. Some people have proposed a diagnostic procedure to identify benign and malignant ascites: the first step is to use high-sensitivity cholesterol as a screen to exclude benign ascites. Cholesterol is significantly increased in malignant ascites, especially when it is greater than 2.85 mol / L; the second step uses a combination of highly specific carcinoembryonic antigen (CEA), lactate deoxygenase (LDH), and ascites ferritin (FA) Content and cytological tests were used as the basis for the diagnosis. Ascites CEA> 15mg / L, ascites CEA / serum CEA> 1; ascites LDH> 1270U / L; or ascites LDH / serum LDH> 1.0, ascites FA> 100g / L, ascites FA / serum FA> 1, malignant ascites may occur The sex is large, if the tumor cells are found in the ascites, the diagnosis can be confirmed; followed by the imaging diagnosis to determine the location and scope of the lesion.

Ascites examination

Routine abdominal puncture, extraction of ascites for laboratory tests can confirm that it is exudate or leakage, and visual inspection can determine that it is serous, bloody, purulent or chyle. Ultrasound may indicate a small amount of ascites or intra-abdominal mass. X-ray, radionuclide scanning, angiography, CT, MRI and other examinations have greater diagnostic value for diseases that cause ascites.

Ascites treatment principles

Cause treatment

Ascites should be formulated according to the primary disease. For example, tuberculous peritonitis should be treated with anti-tuberculosis, liver protection should be given for liver cirrhosis, hemodialysis should be considered for nephrotic syndrome, and surgical treatment for tumorous ascites should be given according to the condition. Drugs, radiotherapy or interventions.

2. Limit sodium and potassium

Limit sodium intake, increase water and sodium excretion, and pay attention to supplement potassium when using diuretics.

3. Application of diuretics

When urine sodium excretion decreases, diuretics are added. Oral sputum accelerates urine, and diuretics in this ratio usually maintain normal potassium. Monitor body weight (weight loss <0.5kg / d), electrolytes, renal function, and avoid NSAIDs.

4. Prevention and treatment of hypoproteinemia

Increase plasma colloid osmotic pressure. Regular infusion of plasma, albumin or fresh blood to increase plasma albumin concentration and plasma osmotic pressure, promote absorption of ascites, increase renal blood flow and glomerular filtration rate.

5. Put a lot of ascites

For refractory ascites and tension ascites, put a large amount of ascites 3 times a week (4 ~ 6L each time), and intravenously input albumin 6 ~ 8gL (30 ~ 40g), which can quickly relieve the symptoms of patients, The same applies to patients. After putting ascites, bandage it.

6. Surgical treatment

For patients with refractory ascites and poor liver function, transjugular intrahepatic portosystemic shunt (TIPS) can be used, which can significantly relieve ascites in the near future. Chemotherapy pumps can be implanted subcutaneously for tumorous ascites to facilitate multiple injections.