Ascites - causes, syndromes and treatment

Ascites - what is it?
Ascites is a variety of complications caused by a number of diseases.

This pathology reveals itself as the accumulation of a large amount of liquid mass inside the peritoneal cavity. Hence the second name “edema of the abdomen”. The accumulated liquid mass increases the volume of the abdomen, causing unpleasant symptoms and secondary dysfunctions of the organs of the peritoneal cavity.

In such a condition, medical intervention is simply necessary, especially if the liquid mass accumulates rapidly.

Manifestations

A small amount of liquid mass accumulated in the abdominal cavity does not reveal itself in any way. How to determine the onset of the disease, since there are no symptoms? Ultrasound comes to the rescue here.

As the disease progresses, a feeling of heaviness appears in the abdomen, and the lower part is subject to dull aching pain. Next comes difficulty breathing, after which there is indigestion in its various varieties, and urination is impaired.

A severe form of pathology can dramatically worsen your health. The state of health leaves much to be desired:

• Unpleasant sensations in the stomach become the norm;
• Shortness of breath appears;
• An umbilical hernia develops;
• Legs swell;
• Internal organs are compressed.

Medical practice is faced with the fact that some patients accumulate up to twenty liters of fluid. As a result, they have:

• Increased pressure inside the peritoneum;
• The diaphragm becomes pressed into the chest cavity;
• Significant difficulty breathing;
• Heart failure develops.

If the order of things is not restored, the following are possible:

• Impaired drainage of the lymphatic system;
• The occurrence of impaired lymphatic drainage in the legs;
• Swelling of the extremities;
• Outflow of lymph to internal organs.

The result of such changes can be disastrous. Atypical cells penetrate from the affected lymph nodes to other organs.

Pathology in a small form can be determined during a medical examination: the abdomen is enlarged, it is saggy when a person is standing, or flattened when a person is lying down. In thin patients, the navel often protrudes.

Determining the pathology at the very beginning of its development is important, since its moderate form is diagnosed in almost half of patients in the early stages of oncology.

Reasons for development

Ascites is a serious complication of stomach and colon cancer, colorectal cancer, malignant tumors of the pancreas, and oncological pathology of the mammary glands, ovaries and uterus. When a large volume of fluid accumulates in the abdominal cavity, intra-abdominal pressure increases, and the diaphragm moves into the chest cavity. This leads to disruption of the heart and lungs. There is a violation of blood circulation in the vessels.

In the presence of ascites, the patient's body loses a large amount of protein. Metabolism is disrupted, heart failure and other imbalances in the internal environment of the body develop, which worsen the course of the underlying disease.

There is always a small amount of fluid in the abdominal cavity of a healthy person. It prevents the sheets of peritoneum from sticking together. The produced intra-abdominal fluid is reabsorbed by the peritoneum.

With the development of cancer, the normal functioning of the body is disrupted. The secretory, resorptive and barrier functions of the peritoneal layers fail. In this case, either excess fluid production or disruption of its absorption processes may be observed. As a result, a large volume of exudate accumulates in the abdominal cavity. It can reach twenty liters.

The main reason for damage to the peritoneum by malignant cells is its close contact with organs that are affected by a cancerous tumor. Ascites in the presence of oncological pathology develops under the influence of the following factors:

• A large accumulation of blood and lymphatic vessels in the peritoneum through which cancer cells spread;
• Tight fit of the folds of the peritoneum to each other, which contributes to the rapid spread of malignant cells to adjacent tissues;
• Germination of a cancerous tumor through the peritoneal tissue;
• Transfer of atypical cells to peritoneal tissue during surgery.

Chemotherapy may be the cause of ascites. The accumulation of fluid in the peritoneum occurs due to cancer intoxication. If the liver is affected by a primary cancerous tumor, metastases of malignant cells from tumors of a different location, the outflow of blood through its venous system is disrupted, and portal hypertension develops - an increase in pressure inside the portal vein. The lumen of the venous vessels increases, plasma sweats from them and accumulates in the abdominal cavity.

The cause of ascites may be peritoneal carcinomatosis. In the presence of a cancerous tumor of the abdominal organs, atypical cells settle on the parietal and visceral sheets of the peritoneum. They block the resorptive function, as a result of which the lymphatic vessels do not cope well with the intended load, and lymph outflow is impaired. Free fluid gradually accumulates in the abdominal cavity. This is the mechanism of development of carcinomatous ascites.

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Causes

The basis for the development of the disease is pathology: during the normal functioning of the peritoneal cavity, no significant amount of liquid mass is discharged. It is only insignificant, just to avoid adhesions from sliding intestinal loops. The liquid released for this purpose constantly flows back.

When the usual operation of this mechanism is disrupted, the function of secretion of the liquid mass is destabilized, as well as the function of its outflow. The consequence of such destabilization is the accumulation of excess liquid mass inside the abdomen.

Causes of pathology in adults

In many cases, pathology develops as a symptom of a number of diseases, including:

• Portal hypertension;
• Cirrhosis;
• Hepatitis;
• Thrombosis of the liver veins.

It is possible that the cause of the pathology is blood oncology, as well as pathologies whose nature has nothing in common with the tumor.
Heart failure can also cause pathology. Problems associated with lymph circulation and the activity of organs such as the thyroid gland and kidneys can also cause pathology.

Protein deficiency

Diagnostic methods

A certain amount of accumulated liquid mass (more than half a liter) can be determined during a medical examination. To confirm a preliminary diagnosis, an ultrasound is necessary.

The main problem is not to detect the liquid, but to identify the cause of its accumulation. Only then will the treatment be effective. To do this, it is necessary to conduct laboratory tests, namely:

• Blood clotting test;
• Biochemistry analysis;
• Analysis of ascitic fluid obtained during laparocentesis

Diagnostics

Doctors identify ascites during an examination of the patient. Oncologists at the Yusupov Hospital conduct a comprehensive examination of patients, which allows them to identify the cause of fluid accumulation in the abdominal cavity. One of the most reliable diagnostic methods is ultrasound. During the procedure, the doctor not only clearly sees the liquid, but also calculates its volume.

In case of ascites, oncologists necessarily perform laparocentesis. After puncturing the anterior abdominal wall, the doctor aspirates fluid from the abdominal cavity and sends it to the laboratory for testing. Computed tomography radiology scans are used to determine the presence of malignant tumors in the liver that cause portal hypertension.

Magnetic resonance imaging makes it possible to determine the amount of accumulated fluid and its location.

Symptoms

Symptomatic manifestations of the disease depend on three main factors - the cause, the volume of accumulated liquid mass, and the rate of accumulation.

Symptoms can appear at any time: sometimes it’s weeks and months, sometimes hours.

As we have already noted, one of the visual symptoms is an enlarged abdomen. Let's add weight gain here.

The patient may develop a feeling of bursting pain, flatulence, belching, heartburn, and nausea.

An increase in the volume of the abdomen entails the appearance of severe shortness of breath, swelling of the extremities, difficulty moving and bending.

Another number of symptoms that a patient may encounter are hemorrhoids, hernias, intestinal prolapse, and the development of varicocele.

Common symptoms of the disease include:

• Feverish state;
• Toxic state;
• Losing weight and at the same time growing belly;
• The saphenous veins of the abdomen are dilated;
• Blueness on the limbs.

Ascites: what is it and how to treat it

Contents ASCITS

REMOVAL OF ASCITES

FEARS AND MISCONCEPTIONS

There is always fluid present in the abdominal cavity of a healthy person. Normally it is no more than 150 ml. Up to 1.5 liters are produced per day, but it is absorbed and does not accumulate. However, with some diseases, the amount of fluid increases - it begins to be produced in excess, or it stops being absorbed.

Together with surgeon Alina Pribytkova, we understand what ascites is and how it is treated.

ASCITS

What is ascites?

Ascites is an accumulation of free fluid in the abdominal cavity. The reasons may be different: most often it is oncology, chronic heart failure, cirrhosis of the liver or kidney disease.

In oncology, the development of ascites most often provokes metastatic damage to the peritoneum, which causes excess fluid production and/or impairs its reabsorption.

There is another cause of ascites in cirrhosis. Normally, the liver synthesizes proteins that help retain fluid inside the vessel. When the liver is damaged, this function suffers, and fluid leaks through the walls of blood vessels more easily.

In chronic heart failure, blood stagnates in the systemic circulation, increased pressure occurs in the vessels and fluid from them leaks into the abdominal cavity. Also, with this pathology, sodium retention occurs in the body, which also contributes to the development of edema.

Kidney disease causes excessive excretion of proteins in the urine (proteinuria). The loss of protein leads to the fact that the liquid part of the blood is not retained in the vessels and leaks through their walls.

Important Ascites indicates deterioration and progression of the disease. In the early stages of the disease, fluid will not accumulate in the abdominal cavity. This happens only in the later stages of the disease, when the body's ability to compensate has been exhausted.

What types of ascites are there?

Ascites is divided into non-tense and tense.

Small or moderate ascites (non-tense) is a condition when fluid has already accumulated inside the abdominal cavity, but this is not enough to prescribe a procedure for removing ascites: there are no signs of tension, the abdominal wall is soft, pliable during palpation - “pressed”. In this case, surgical evacuation of fluid (laparocentesis) is not used due to the high risk of injuring internal organs, since with non-stressed ascites the distance between the internal organs and the anterior abdominal wall is not enough for manipulation due to the small layer of fluid between them.

With intense ascites, the abdomen becomes greatly enlarged, the skin is tightly stretched, shiny, and the navel may protrude, as during pregnancy. When palpating the anterior abdominal wall, great resistance is felt, which is created due to fluid pressure from the inside.

In quantitative terms, ascites becomes tense when fluid accumulates approximately over 7 liters, but all people are different: physique, parameters, body constitution, size of the abdominal cavity. Therefore, doctors do not focus on the volume of fluid: they perform an ultrasound of the abdominal cavity, examine and palpate the abdomen.

In a person with short stature and asthenic physique, ascites can be tense and with the accumulation of 5 liters of fluid. At the same time, in a tall person with a hypersthenic physique, 10 liters of free fluid may not give signs of tense ascites.

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Care

Characteristic symptoms appear with tense ascites: a large belly with a protruding navel, like in pregnant women, a feeling of fullness in the abdomen and pressure on the stomach, nagging pain in the abdomen, shortness of breath, problems with eating due to the pressure of fluid on the stomach - belching, nausea or even vomiting, restriction of physical activity. The accumulation of fluid leads to increased intra-abdominal pressure and pushing of the diaphragm into the chest cavity. As a result, the respiratory movements of the lungs are significantly limited (up to the development of respiratory failure), the activity of the heart is disrupted, and the resistance to blood flow in the abdominal organs increases, the functions of which are also impaired. With long-term ascites, the outflow of lymph from the lower extremities and abdominal organs is disrupted, and swelling of the lower extremities occurs. People note a significant increase in general weakness.

Should we sound the alarm? When?

Ascites does not occur overnight; fluid accumulates gradually. A person may not even notice it and think that he is gaining weight. Usually, suspicions arise when specific symptoms occur: an enlarged abdomen, a feeling of fullness in the abdomen and pressure on the stomach, nagging pain in the abdomen, shortness of breath, belching, nausea or even vomiting, limitation of physical activity, swelling of the lower extremities, general weakness.

If a person notices signs of ascites, you need to see a doctor and do an ultrasound of the abdominal cavity: then the doctor will give recommendations and tell you whether the ascites needs to be removed surgically.

If a person is regularly observed by a doctor, then ascites can be detected during routine instrumental examinations (ultrasound, CT), during examination. If necessary, the doctor will prescribe additional examinations and give recommendations.

REMOVAL OF ASCITES

How is ascites removed?

To treat mild ascites, diuretics can be prescribed, which are most effective in cases of ascites resulting from chronic heart failure or cirrhosis of the liver. However, it should be remembered that there are refractory ascites, that is, resistant to diuretic therapy, when the use of medications does not have a positive effect. With prolonged, uncontrolled use of diuretics, the patient develops water and electrolyte disturbances, dehydration, and a drop in blood pressure. With ascites of an oncological nature, diuretics are most often ineffective.

For tense ascites, doctors perform laparocentesis: under local anesthesia, a puncture of the anterior abdominal wall is performed and the fluid is evacuated.

The frequency of the procedure depends on how quickly the fluid accumulates, on the existing pathology and the degree of its progression. For some, tense ascites may recur within a few months, for others within a week/month.

For ascites, the cause of which is chronic heart failure or cirrhosis of the liver, diuretics are also prescribed after surgical removal of the fluid, if the person’s condition allows.

How is the procedure done?

If there is a clinical picture of tense ascites, an ultrasound of the abdominal cavity is performed to assess the level of free fluid and determine the safest point for puncture of the anterior abdominal wall.

They talk with the person: they explain to him the principle of the planned manipulation, the possible risks, as with any invasive intervention. After which, if he agrees to the manipulation, the person signs an informed consent to the intervention. If a person is legally capable, he must sign the document himself; if not, then this is done by his official representative.

The area of ​​the planned puncture of the anterior abdominal wall is treated with an antiseptic solution and then anesthetized layer by layer with a 5-10 ml syringe with a local anesthetic solution (lidocaine, novocaine - if the patient is allergic to these drugs, tell the doctor!). At the same time, the location of the needle is monitored - when it enters the abdominal cavity, ascitic fluid appears in the syringe.

Then, using a long hollow needle - or a special instrument - a stylet with a trocar, depending on the equipment chosen for the manipulation - the doctor pierces the anterior abdominal wall at a previously designated point and penetrates the abdominal cavity, receiving a flow of fluid through the needle. A plastic catheter is passed through the needle into the abdominal cavity, and the needle itself is removed. The plastic catheter is sutured to the skin to prevent it from moving or falling out. Through the catheter, the outflow of fluid goes into a vacuum bag attached to it (for better outflow, the bag should be below the level of the bed - on the floor or attached to the side of the bed).

The most favorable is fractional removal of fluid - 3-4 liters per day, as this will help avoid a sharp drop in pressure inside the abdominal cavity.

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Care

The drainage is in the abdominal cavity for several days, since it is fixed to the skin with a suture - you can turn, eat, move, the tube will not go anywhere. The puncture site must be treated with an antiseptic once a day and covered with an aseptic bandage. Usually, drainage does not cause pain; on the first evening after the puncture, there may be a slight pain in the area of ​​the puncture of the abdominal wall, then, if there is no planned pain therapy, you can take a painkiller from the NSAID group (if there are no contraindications). But the drainage tube can touch the peritoneum, which lines the anterior abdominal wall from the inside and internal organs, and this in turn can cause discomfort.

After removing the ascites, the drainage from the abdominal cavity is removed. A suture may be placed over the punctured area to prevent any remaining fluid from leaking out. It is impossible to remove everything “dry”, since residual fluid remains in the pelvic cavity and between the intestinal loops, and its accumulation does not stop after laparocentesis. If a suture was not applied, then after a while the tissues “stick together” and the liquid stops leaking.

If a suture was placed after removing the drainage, then it must be treated with an antiseptic solution, the dressings should be changed once a day, healing usually occurs in 7-10 days. If a suture was not applied, the principle of care is the same, the difference is that in the first day or two after removal of the drainage, there may be a need to change the dressing more often due to slight leakage of fluid.

There are ascites that are difficult to evacuate: the liquid may have a gel-like nature, a heterogeneous structure, which can clog the drainage, or in rare cases, the liquid may not flow through the drainage at all due to its excessive viscosity. If the drain is blocked, the doctor will flush it with sterile saline to restore drainage.

Patient N., 56 years old. Diagnosis: Ovarian cancer, disease progression, peritoneal carcinomatosis, tense ascites. According to ultrasound, ascites is gel-like in nature, with a volume of about 10 liters. A decision was made to perform laparocentesis. As a result of the manipulation, practically no liquid flows through the installed plastic catheter due to an excessively thick jelly-like consistency that cannot be actively aspirated (that is, removed by attaching a syringe to the catheter). Next, a repeat laparocentesis was performed using a large-diameter trocar (hollow metal tube), with which it was possible to evacuate no more than 3 liters of secretion. The patient was recommended symptomatic therapy; further attempts to evacuate secretions are inappropriate due to the risk of complications.

The laparocentesis procedure is not very long, in typical cases it takes no more than 15-20 minutes. There are technically complex cases that require more time: if a person has excessively developed subcutaneous fat, there have been surgeries on the abdominal organs in the past, massive growth of metastases in the peritoneum, the presence of voluminous tumors in the abdominal cavity. In such cases, puncture can be performed directly under ultrasound guidance.

Is it possible to carry out the procedure at home? Can I go home immediately after the procedure?

Removal of ascites is a surgical intervention; it is not performed at home, like any other surgical operation: there is no necessary equipment, conditions, and sterility cannot be ensured.

It will also not be possible to go home with drainage, since it is a foreign body. It must be removed at a medical facility. At home, if the drainage is handled incorrectly, it can become dislodged/fall out, which can lead to infection. It is not recommended to remove ascites “in one day”; it is better to do it gradually, over several days, since the immediate removal of a large amount of fluid can provoke a sharp drop in pressure inside the abdominal cavity, which will entail a drop in a person’s systemic blood pressure and a deterioration in general well-being.

Are there any contraindications to the procedure? When can doctors refuse to perform a procedure?

The procedure is not performed when the ascites is not tense or is not tense enough, since in these cases internal organs can be damaged. With mild ascites, there are no painful symptoms, which is the reason to perform laparocentesis. It must be remembered that evacuation of fluid does not cure the disease, but only alleviates the painful manifestations that arise when there is a large accumulation of fluid.

Evacuation of fluid is not carried out if a person is in extremely serious condition, in other words, when the life prognosis is calculated in hours or days, and this means a complete depletion of the body’s compensatory forces. And the loss of protein, electrolytes, a decrease in intra-abdominal pressure with general hypotension (which is always present in the last days and hours of life) can only worsen the patient’s condition; after the manipulation he may not experience relief, and the stress of the intervention will add additional painful sensations to the already extremely serious condition. And we remember that the manipulation is invasive in nature, that is, like any surgical intervention, it can have a number of complications.

The procedure may be refused when a critical accumulation of fluid coincides with the transition to the terminal stage of the disease. Of course, the fluid can be evacuated: technically this is possible for almost any patient's condition, but the person's general condition will continue to get worse as the underlying disease progresses, and the fluid, even during the evacuation process, can quickly accumulate again. As mentioned above, it must be remembered that laparocentesis does not cure the disease, but only alleviates the painful manifestations that occur with a large accumulation of fluid, and it is necessary to compare the expected benefits of the manipulation and the existing risks of causing additional discomfort to the person at the end of life.

For example, according to abdominal ultrasound, the volume of ascites is 8 liters. The doctor puts in a drainage, but the fluid accumulates every day. A person gets 8 liters, 10 liters, 12 liters removed - so a week passes, and the drainage is still standing. He does not experience relief from the manipulation, and the drainage located in the abdominal cavity causes discomfort and complicates the care of the patient.

We already know that when ascitic fluid is removed, a person loses valuable substances - proteins and electrolytes. The protein concentration in serous ascitic fluid is usually relatively low, but with massive ascites, its total loss can be significant, especially with frequent repeated removal of large amounts of fluid, and the loss of protein is combined with the loss of salts, which leads to the development of severe protein and electrolyte deficiency.

Frequent laparocentesis or fractional pumping of fluid from the abdominal cavity over a long period of time will do more harm than good, so transition to the terminal stage of the disease is a contraindication to the procedure.

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Laparocentesis is not performed if:

• blood clotting is impaired (the risk of bleeding increases);
• decreased platelet levels (especially after chemotherapy);
• a pronounced adhesive process has been diagnosed (dense connective tissue (cords, adhesions) is formed in the abdominal cavity after inflammatory processes, injuries or surgical interventions, which “solder” the internal organs in the peritoneum, lining the anterior abdominal wall from the inside) - this is a risk of injury to the internal organs;
• peritoneal carcinomatosis was diagnosed, when the abdominal cavity is so affected by metastases that a safe area for puncture is not visualized, which is also fraught with injury or bleeding;
• a person has an unfavorable life prognosis (days, hours).

FEARS AND MISCONCEPTIONS

Is it possible to die from ascites or from the procedure for its removal?

Ascites, like the procedure for removing fluid from the abdominal cavity, cannot cause death. Ascites is not an independent disease, but usually acts as a symptom of one or another serious disorder in the body.

It should be remembered that with laparocentesis, as with any surgical intervention, even in the absence of contraindications, there is a low risk of complications.

Can ascites occur due to medications? Chemotherapy?

Drugs and chemotherapy cannot cause ascites.

Important: People with ascites are advised to evacuate it before chemotherapy to increase effectiveness.

To prevent fluid from accumulating, should you drink less water?

It is necessary to maintain a water-drinking regime, drink as needed. Refusal to drink can worsen the general condition and provoke the appearance of additional painful symptoms against the background of dehydration.

What happens if ascites is not removed?

Fluid in tense ascites does not mechanically damage internal organs, but can put pressure on the stomach, intestines, diaphragm, lymphatic system and disrupt their functions. This can cause breathing problems, constipation, nausea, vomiting, hiccups, belching, heartburn, loss of appetite, swelling of the lower extremities, even lymphorrhea (“sweating” of fluid through the skin). Against the background of the underlying disease, pain may intensify, and a feeling of tension and fullness in the abdominal cavity may appear.

It happens that with a very large accumulation of fluid in the abdominal cavity (20 liters or more), the pressure on the tissue is so high that the fluid begins to find “weak spots” in the abdominal wall and seep through them (scars after operations and even the navel).

Can internal organs be damaged during the procedure?

With mild ascites, there is a high probability of damaging internal organs, so in this case laparocentesis is contraindicated. If there is a significant amount of fluid and signs of tension, the risk of injury is minimal. Complications are possible with any operation, but with the correct indications and taking into account all contraindications, in the vast majority of cases laparocentesis occurs without complications or injuries.

Can drainage damage internal organs?

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Care

The drainage tube is soft, it will not damage the internal organs, but it can touch the peritoneum lining the anterior abdominal wall from the inside and internal organs, and this in turn can cause discomfort.

Is it possible to lie on your stomach with ascites? Is the blow dangerous?

Lying on the stomach for a person with tense ascites is extremely uncomfortable, but this is not prohibited. Most often, a person takes a position on his side. Any blows to the stomach in everyday life are also not dangerous: it is a liquid, it “flows around” the internal organs. Blows of excessive force are equally dangerous for internal organs, regardless of the presence of fluid in the abdominal cavity.

Are emergency operations performed for ascites?

If, for urgent reasons, a person with ascites suddenly finds himself on the operating table, this is not a contraindication to emergency surgery; surgeons simultaneously remove free fluid; all operating rooms are equipped with electric aspirators.

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We would like to thank the volunteers of the Vera Hospice Fund for their assistance in preparing the material.

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Types of disease

In the main classification, to differentiate pathology, the level of protein in the accumulated fluid is taken into account. According to this indicator, the disease is divided into:

• Exudative (25 g/l or more);
• Transudative (<25 g/l).

Such a division makes it possible to understand, albeit indirectly, what is the cause of the development of the disease.

Today, another indicator is used in medical practice - SAAG.

If this gradient is > 1.1, then most likely the cause of the disease is cirrhosis, heart failure, etc. All of them increase the pressure in the venous trunk.

If the gradient index is <1.1, then the cause of the disease can be considered pancreatitis or an oncological process.

Taking into account the clinical course of the disease, it is necessary to highlight the following varieties, which will be discussed below.

1. Severity of the current:

• First degree. There are no symptoms, diagnosed by examination and ultrasound.
• Second degree. The abdomen is slightly enlarged.
• Third degree. The abdomen is significantly enlarged.

1. An uncomplicated option. There are no signs of infection of the accumulated fluid mass and abnormalities in kidney function.
2. Refractory ascites:

• Unaffected by diuretics;
• Not controlled by diuretics.

Non-cancerous ascites

Ascites is a consequence of various disorders that occur in the body. Treatment tactics depend on the pathological process that caused the accumulation of fluid in the abdominal cavity:

• To treat acute heart failure, cardiologists at the Yusupov Hospital prescribe metabolites, beta blockers, and ACE inhibitors to patients;
• For infectious and toxic liver lesions, therapy with hepatoprotectors is carried out;
• If ascites has developed due to low protein levels in the blood, albumin infusions are performed;
• Ascites that develops as a result of peritoneal tuberculosis is treated with anti-tuberculosis drugs.

To remove fluid from the body, patients with ascites are prescribed diuretics. The main method of eliminating ascites is to remove accumulated fluid by puncturing the abdominal wall, followed by installing drainage. For persistent ascites, peritoneal fluid is reinfused after filtration. A peritoneovenous shunt for abdominal ascites ensures the flow of fluid into the general bloodstream. To do this, surgeons form a structure with a valve, through which fluid from the abdominal cavity enters the superior vena cava system during inhalation.

Omentohepatophrenopexy for abdominal ascites is performed to reduce pressure in the venous system. The surgeon sutures the omentum to the diaphragm and liver. Then, during breathing movements, the veins are unloaded from blood. As a result, the release of fluid through the vascular wall into the abdominal cavity decreases. As a result of deperitonization (excision of areas of the peritoneum), additional outflow pathways for peritoneal fluid are created.

Pathology and cancer

Medical statistics and practice show that the most common diseases leading to the accumulation of liquid mass in the peritoneal cavity are oncological forms:

• Ovaries;
• Mammary glands;
• Uterus;
• Stomach;
• Colon.

A liquid mass accumulates with a tumor due to damage to the peritoneal lining. Atypical cells, having settled on it, cause disruption of lymphatic drainage, which, in turn, impairs fluid absorption. This is very common, for example, in gastrointestinal oncology.

If we take an organ such as the liver, the picture will be different. A tumor or metastasis localized in an organ causes compression of the venous system of the organ and disruption of normal venous outflow from the intestine. In this case, the pathology develops rapidly and is more severe. About fifteen percent of ascites in cancer processes is diagnosed in this form.

Forecast

Ascites in cancer significantly worsens the general well-being of the patient. As a rule, such a complication occurs in the later stages of oncology, in which the survival prognosis depends on the nature of the tumor itself and its distribution throughout the body.

Life expectancy with ascites depends on the following factors:

• Functioning of the kidneys and liver;
• Activities of the cardiovascular system;
• The effectiveness of therapy for the underlying disease.

The development of ascites can be prevented by an experienced doctor observing the patient. Doctors at the Yusupov Hospital have extensive experience in dealing with various types of cancer. Qualified medical personnel and the latest equipment allow for accurate diagnosis and high-quality, effective treatment in accordance with European standards.

Specifics of treatment for cancer

Conservative methods are effective in treating pathologies of only minor and moderate severity. The diuretics used here allow you to remove up to a liter of liquid mass per day.

However, the surgical option is preferable. It is used when:

• The disease cannot be treated by other means;
• A significant form of the disease, in which it is necessary to evacuate up to ten liters of liquid mass at a time;
• A form of the disease that requires combined manipulation, including evacuation of a volume of liquid mass of up to seven liters on the first day and evacuation of the remaining mass at a rate of no more than one liter per day for a week.

The operation is performed on an empty stomach and with an empty bladder. The patient is positioned in a sitting position (lying down is possible).

Before the puncture, local anesthesia is performed, then the puncture is performed under ultrasound control.

As a rule, no more than five liters of liquid mass are evacuated at a time. To maintain blood pressure, it is pumped slowly.

It is important for the patient to lie on the side free from the puncture for several hours. If during this time all the planned liquid mass is not evacuated and continues to accumulate, a special reservoir is applied.

When removing large amounts of fluid, it is important that the patient does not experience protein deficiency. To do this, the patient is injected with albumin.

In modern practice, special catheters are used to evacuate accumulated fluid, and some patients undergo the procedure of omentohepatophrenopexy. This is an important part of palliative treatment.

Treatment

Drug therapy for ascites is not carried out due to low effectiveness. Aldosterone antagonists and diuretics normalize water-salt metabolism and prevent excess secretion of peritoneal fluid. Oncologists at the Yusupov Hospital offer palliative surgery to patients with ascites in the late stages of cancer:

• Omentohepatophrenopexy;
• Deperitonization;
• Installation of a peritoneovenous shunt.

Doctors at the Oncology Clinic carry out traditional or intracavitary chemotherapy for ascites - after removing the fluid, a chemotherapy drug is injected into the abdominal cavity. Laparocentesis is performed to remove fluid. The procedure is not performed if the following contraindications are present:

• Adhesive process inside the abdominal cavity;
• Severe flatulence;
• Perforation of the intestinal walls;
• Purulent infectious processes.

Laparocentesis is prescribed in cases where taking diuretics does not lead to a positive result. The procedure is also indicated for resistant ascites.

Laparocentesis is carried out in several stages using local anesthesia:

• the patient is in a sitting position, the doctor treats the subsequent puncture site with an antiseptic and administers painkillers;
• An incision is made in the abdominal wall along the linea alba at a distance of 2-3 centimeters below the navel;
• The puncture itself is performed using a trocar using rotational movements. A special flexible tube is attached to the trocar, through which excess fluid is removed from the body. The fluid is pumped out quite slowly, and the doctor constantly monitors the patient’s condition. As the exudate is removed, the nurse tightens the patient's abdomen with a sheet to slowly reduce the pressure in the abdominal cavity;
• After the fluid is pumped out, a sterile bandage is applied to the wound.

Using laparocentesis, up to 10 liters of fluid can be removed from the patient’s body. In this case, it may be necessary to administer albumin and other drugs to prevent the development of renal failure.

If necessary, temporary catheters can be installed in the abdominal cavity, through which excess fluid will gradually be removed. It should be noted that the use of catheters can lead to a decrease in blood pressure and the formation of adhesions.

There are also contraindications to laparocentesis. Among them:

• pronounced flatulence;
• adhesive disease of the abdominal organs;
• stage of recovery after surgery on a ventral hernia.

Diuretics are prescribed to patients with developing ascites in cancer over a long course. Such drugs as Furosemide, Diacarb and Veroshpiron are effective.

When taking diuretics, medications containing potassium must also be prescribed. Otherwise, there is a high probability of developing disturbances in water and electrolyte metabolism.

Dietary nutrition primarily involves reducing the amount of salt consumed, which retains fluid in the body. It is also important to limit the amount of fluid you drink. It is recommended to include more foods containing potassium in your diet.

After removal of fluid from the abdominal cavity, patients are provided with a balanced and high-calorie diet. This allows you to meet the body's needs for proteins, carbohydrates, vitamins and minerals. Fat consumption is reduced.