Ascites

Ascites is accumulation of (usually) noninflammatory fluid in peritoneal cavity. It is one of liver cirrhosis consequences. All the patients with arcites usually have liver cirrhosis (or other liver fibrosis) and portal hypertension. In peritoneal cavity is physiologically 150 ml of fluid produced by mesothelial cells, larger volume is considered as ascites. 10 liters of fluid is no exception.

Patophysiology
Formation of ascites is mutifactorial process. There are several theories (several factors) about its formation:
 * sodium and watter retention - is renal dysfunction (higher reabsoption of natrium in renal tubules), it causes formation of swelling and ascites;
 * hypoalbuminemia with reduced plasma oncotic pressure can be reason for migration of fluid from plasma to extravasal space and peritoneal cavity;
 * vasodilatation in splanchnical circulation - mediated by nitrid oxide, it causes larger blood volume to splanchnical circulation;
 * portal hypertension - higher ressistance of liver sinusoides supportes migration of fluid to extravasal space in liver, their lymphatic veins can drain away just a part of this fluid;
 * baroreceptor-mediated stimulation of renin-angiotensin system and maybe more...

Diagnostic and clinical features

 * physical examination - increasing abdominal girth, percussion - undulation of fluid (fluid wave), "caput medusae" - dilated subcutaneous veins of abdomen, shortness of breath - because of elevation of the diaphragm, dyspepsia;
 * USG - is the most basic diagnostic method;
 * lab - signes of liver cirrhosis (elevation of AST and ALT, hypoalbuminemia, decrease of coagulation factors produced by liver, increase of INR), increse of natrium.

Conservative therapy

 * diet - salt restriction, < 3 g of salt per a day ;
 * diuretics:
 * spirinolactone to 400 mg/day (natrium and water elimination) ;
 * furosemid 160 mg/day (water elimination) ;
 * nonselective β-blockers - propranolol, nadolol (portal hypertension therapy).

Invasive therapy
Invasive therapy is for patients with refractory ascites.
 * paracentesis - usually 5 l of fluid or all the fluid (often paracenthesis is risk of infection), 200 ml of fluid should be used for laboratory and hematological examination (exclusion of peritonitis...) ;
 * TIPS - transjugular intrahepatic porosystemic shunt;
 * surgical portocaval shunt (but TIPS is prefered).

Other causes of ascites

 * Budd-Chiari syndrome (trombosis of hepatic veins);
 * heart failure;
 * kwashiorkor;
 * peritoneal carcinomatosis;
 * pancreatitis.

Related articles

 * Cirrhosis
 * Portal hypertension
 * Esophageal varices