Ascites

ASCITES, ascites (from Greek ascos-bag, receptacle for liquid, wineskin), a term used to denote abdominal dropsy, i.e., the accumulation of serous fluid in the peritoneal cavity, a transudate. Some (e.g., the French school) tend to use the term A. in a broader sense, calling A. any accumulation of fluid in the abdominal cavity (both non-inflammatory and inflammatory); it is more correct, however, to call A. only accumulations of fluid (transudate) of non-inflammatory origin, relating inflammatory accumulations of exudate to the concept of peritonitis (see). Ascites may be a manifestation of general dropsy of cardiac, renal, or cachectic nature (see Dropsy), or it develops as a result of local circulatory disorders in the abdominal cavity. The most frequent A. of the latter kind is the result of blood stasis in the portal vein system due to narrowing or closure of its lumen, which is observed in atrophic (Laënnec's) cirrhosis of the liver, in thrombosis or compression (for example, by a tumor) of the portal vein. Some types of A. are associated with impaired outflow of lymph from the abdominal cavity (e.g., A. with dissemination of a tumor in the peritoneum and in some forms of tuberculous peritonitis). In general, A. is never an independent disease, but represents a particular manifestation or consequence of some other disease. (For details of the pathogenesis of A.-see Dropsy.) The fluid accumulating in the abdominal cavity in A. (so-called ascitic fluid) is watery in appearance, colorless or light yellow, specific gravity 1004-1014, weakly alkaline reaction; protein is present, as in transudates in general, in an amount not exceeding 2-2.5% (unlike exudates, in which the amount of protein is not less than 3%); chlorine, soda-0.6%, urea-0.04-0.12% and small amounts of uric acid, cholesterol, creatinine; in diabetics, the fluid may contain sugar. When fresh ascitic fluid is cooled, a fibrin clot sometimes forms in it. Microscopically, in the sediment or centrifugate of ascitic fluid, small amounts of desquamated cells of the peritoneal covering epithelium, single leukocytes, often fatty-degenerated, and lymphocytes are found (a large number of leukocytes indicates the presence of an inflammatory process, i.e., peritonitis). In a cadaver, ascitic fluid often has a turbid, opalescent appearance due to the admixture of a large number of postmortem desquamated cells of the peritoneal epithelium. An admixture of bile gives the ascitic fluid an amber-yellow or olive-yellow color, an admixture of blood (often indicating a malignant neoplasm of the abdominal cavity) gives it a reddish tint. Chylous ascites (A. chylosus) is observed in ruptures of the thoracic lymphatic duct (ductus thoracicus) or of the lacteal vessels of the mesentery, as a result of which chyle is exuded into the abdominal cavity; the ascitic fluid becomes turbid, whitish in appearance, resembling diluted milk, and microscopically, a large number of small fat droplets are found in it. This true chylous A. must be distinguished from pseudo-chylous, or fatty A., in which the fluid has a milk-like character not from an admixture of chyle, but from the presence in it of a large number of fatty-degenerated cells (epithelium, leukocytes, sometimes cells of a cancerous tumor). The amount of fluid in A. can reach 20 liters or more; accumulation of fluid usually occurs gradually (only in cases of rapidly developing complete thrombosis of the portal vein is very rapid development of A. possible). Objective symptoms of A. are usually manifested only when there is at least 1 liter of fluid in the abdominal cavity and consist in gradually increasing enlargement of the abdomen, in the appearance of dull percussion sound in the dependent parts of the abdomen, shifting with a change in the patient's position, and (with large accumulations) in the sensation of fluctuation. For differential diagnosis, one must keep in mind the possibility of false fluctuation in meteorism and the possibility of fluctuation not from A., but from the presence of an accumulation of fluid in some organ or tumor (distended urinary bladder, hydronephrosis, ovarian cyst). In A. developing in cirrhosis of the liver, marked dilation of the veins of the abdominal wall wall ('caput medusae') is often observed as a sign of established collateral outflow of venous blood from the abdominal cavity. With significant A., the skin of the anterior abdominal wall is tense, shiny, and often stretch marks (striae distensae) appear in it; sometimes there is protrusion of the umbilical region. A long-existing large A. can lead to atrophy of the muscles of the abdominal wall, to compression and atrophy of the organs of the abdominal cavity. Among functional disorders in ascites, besides those related to the primary disease, one must mention dyspnea associated with the high position of the diaphragm. An important diagnostic method in unclear cases is abdominal puncture and examination of the obtained fluid. The course of A. is varied and is in close dependence on the primary disease. Spontaneous disappearance of A. sometimes occurs (Chauffard) as a result of adhesions of the liver, spleen, and greater omentum to the anterior abdominal wall, which provides wide opportunity for collateral outflow of venous blood from the abdominal cavity. Treatment should be fundamentally directed at the causative disease causing ascites. Measures aimed at preventing the accumulation of ascitic fluid include a salt-free diet (not always effective) and, mainly, care to maintain diuresis and intestinal function at an adequate level. Treatment by injecting ascitic fluid under the skin (autoserotherapy) is used, but rarely meets with success. Extensive and recurrent A., mainly those developing in atrophic (Laënnec's) cirrhosis of the liver, require surgical intervention. In such cases, the fluid is drained by puncture using a trocar - a hollow metal cannula of various calibers (3-5 mm) with a sharp obturator inside. This tube, observing all rules of asepsis, is inserted in the middle between the navel and the symphysis, with the patient in a sitting position, and the obturator is withdrawn. Another site for trocar insertion is the so-called point of Monroe-the middle of a line drawn between the navel and spina ili anterior superior (in the latter place it is easier to injure art. epigastrica superf., and therefore it is more dangerous). It is better to extract the fluid with intervals of 1-2 minutes, covering the trocar opening with a finger. The fluid must be drained every 2-3 months, and sometimes more frequently, depending on the rate of its accumulation. In the case of Troisier-Siculle, the total number of punctures was 18, with 165 liters of fluid drained. As a result of this treatment, a series of adhesions between the peritoneum and the organs of the abdominal cavity, mainly the intestines, sometimes develop, which may endanger the danger of perforation of the intestinal wall and severe inflammation of the peritoneum. In some rare cases, these adhesions lead to spontaneous healing. Possible complications during puncture: cessation of respiration and acute dilatation of the heart as a result of rapid changes in blood and intrathoracic pressure and bleeding- when an artery or dilated vein is injured. Injury can be dangerous in cases where the artery bleeds not outward, but inward, into the abdominal cavity; prolonged leakage of ascitic fluid from the puncture site inward, into the tissues of the abdominal wall, may occur, causing severe edema. In this case, spontaneous autoserotherapy occurs. A. in cirrhosis of the liver has in some cases been proposed to be treated by more complex operations. Methods of such treatment are divided into two groups: 1) radical, aimed at creating a new bypass pathway for blood to pass from the portal vein system to the inferior vena cava, and 2) palliative, creating a constant outflow of fluid from the peritoneal cavity. The first methods are an imitation of nature, which in the case of a long-lasting cirrhosis creates such bypass anastomoses, in a winding way, through the dilated cutaneous veins of the abdominal wall. For this purpose, Talma proposed in 1898 to suture the omentum and spleen to the abdominal wall. This operation is performed as follows: the abdominal cavity is opened, the fluid is drained, then the superficial layers of the inner wall of the abdomen (resp. peritoneum) are removed with a sharp spoon, to the resulting area, bared from the peritoneal covering, the spread omentum is sutured with the calculation that the plane of contact of the fixed omentum and the abdominal wall is as large as possible, after which the abdominal wound is tightly closed. A number of modifications of this operation have been proposed, aimed at increasing the surface of contact of the viscera with the peritoneum. Ridygier proposed placing the spleen in a special pocket made between the peritoneum and the muscles, Narath placed the omentum between the layers of the abdominal wall. Bogoyavlevsky used for this purpose temporary tamponade of the abdominal cavity. Talma's operation, according to Hopfner's statistics from 635 cases, gave 34.6% recovery, according to Kozlovsky-29%. With the development of vascular suture technique, the idea arose to perform direct anastomosis between the portal and vena cava systems.

Vidol, Thierry, de Martel, and Lenoir created an anastomosis between the portal and inferior vena cava, so-called Eck's fistula, with ligation of the portal vein above the anastomosis, but did not achieve success. The first successful case without ligation of the portal vein belongs to Rosenstein, who performed the operation in 1912 on a woman suffering from hepatic cirrhosis and achieved temporary success. Bogoraz performed in 1912 the implantation of the superior mesenteric vein into the inferior vena cava, and his patient recovered and experienced relief for the duration of observation. This operation is performed as follows: after opening the abdomen, the trunk of v. mesentericae superioris is freed in the mesentery, its central end is ligated, and the peripheral end is clamped with a Göpfner clamp, and the vein is cut. Then the wall of the inferior vena cava is clamped on the side with a curved soft clamp, and the peripheral end of v. mesent. superior is sutured into the opening made in this wall. In total, three cases of this operation are known in the literature (two by Bogoraz, one by Krestovsky). All resulted in improvement in the sense that immediately after the operation, fluid did not accumulate or accumulated much more slowly. - Among palliative methods aimed at draining the abdominal cavity, the Ruotte operation should be mentioned first, which consists of making a large incision above v. saphena magna and the femoral canal, v. saphena magna is separated for 7-10 cm and cut in the upper third of the thigh. The peripheral end is ligated tightly, and the central end, above the Poupart's ligament, bent upward, is sutured directly into the abdominal cavity; thus, outflow of fluid directly into the bloodstream is created. The author reports good results in his two cases and six collected from the literature. Terebinsky obtained improvement in 4 out of 8 cases. However, this operation did not become widespread, as the vein usually atrophies. - Next follows a series of cases where fluid is drained directly from the peritoneum into the subcutaneous tissue either by means of silk threads passed from the abdominal cavity under the Poupart's ligament under the skin of the thigh (Handley), or by means of a silver tube placed as a drain from the abdominal cavity under the skin of the abdomen (Perimov), or by means of a dense bovine artery (Schepelmann), etc. All these methods did not become widespread. Kalb proposed to create a window the size of a 2-3 kopeck coin in the peritoneum on both sides outward from the large intestine and correspondingly in the muscle in the area of trig. Petiti so that ascitic fluid would seep under the skin. In his three cases, he achieved temporary success, as it was a case of peritoneal cancer, which was the cause of death of the patients. Shaak performed Kalb's operation in three cases, where he combined it with Talma's operation; in one case a good result was obtained, and in two the outcome was fatal.