Ascites

　　The causes of ascites include the following points.

　　Systemic factors

　　(1) Decreased colloid osmotic pressure of plasma: The colloid osmotic pressure of plasma mainly relies on albumin to maintain plasma albumin below 25g/L or accompanied by portal hypertension. Fluids are prone to leak from capillaries into the interstitial space and peritoneal cavity. If water leaks into the peritoneal cavity, it forms ascites. This condition is seen in severe liver dysfunction, advanced liver cirrhosis (reduction in protein synthesis), malnutrition (insufficient protein intake), nephrotic syndrome, and protein-losing gastrointestinal diseases.

　　(2) Sodium and water retention: Common in renal insufficiency and advanced liver cirrhosis with secondary aldosterone excess. In liver cirrhosis and right heart failure, the decreased activity of natriuretic factors increases the reabsorption of sodium by the renal proximal tubules. In recent years, it is believed that the sodium reabsorption mechanism of the proximal tubules is more important than the action of aldosterone on the distal tubules. Heart failure and advanced liver cirrhosis cause a significant decrease in effective blood volume, stimulating volume receptors and glomerular capsules.

　　Local factors

　　(1) Increased hydrostatic pressure of the fluid: Due to liver cirrhosis and external compression of the portal vein or its own thrombosis, the pressure in the portal vein and its capillaries increases, leading to ascites.

　　(2) Increased lymph flow and obstruction of return: During liver cirrhosis, due to the significant increase in portal vein and sinus pressure, the subcapsular lymphatic vessels absorb a smaller area like withered branches, causing an increase in lymph fluid growth. This exceeds the capacity of lymphatic circulation reabsorption, leading to lymphatic stasis. Lymph fluid leaks out through the peritoneal visceral layer or the liver surface into the peritoneal cavity, aggravating the accumulation of ascites. This can occur in conditions such as obstruction of the thoracic duct or chyle pool due to retroperitoneal tumors, mediastinal tumors, filariasis, as well as traumatic rupture, chyle leakage into the peritoneal cavity forming chyle ascites.

　　(3) Increased permeability of peritoneal blood vessels: Inflammation of the peritoneum, infiltration of tumors, or perforation of organs can all stimulate the increased permeability of peritoneal blood vessels, causing ascites. This can be triggered by the stimulation of bile juice, pancreatic juice, gastric juice, and blood.

　　(4) Rupture of abdominal viscera: Rupture and perforation of solid or hollow organs can respectively cause pancreatic ascites, biliary ascites, hemorrhagic ascites, and blood peritoneum.

　　1. Inducing hemorrhage

　　With the increase of ascites, more tissue fluid is lost in the blood, making the blood thick and slow, which can cause hypotension or shock. In recent days, patients may experience symptoms such as gum bleeding, mucosal bleeding of the skin, and purple spots at the site of needle injection. Hiccups may indicate symptoms of gastrointestinal bleeding.

　　2. Leading to peritoneal infection

　　The solution inside the abdomen is the secretion of tissue fluid in the body, which contains a variety of nutrients and is conducive to bacterial growth. Especially for patients who undergo peritoneal puncture, it is more likely to cause secondary infection, leading to peritonitis and other diseases, not only causing an increase in abdominal pressure, but also bringing other diseases.

　　3. Leading to liver failure in patients

　　Excessive ascites can further worsen the liver environment, leading to liver failure. The symptoms of fatigue become more obvious, and self-care becomes extremely difficult. Breathing becomes short, and it is not possible to breathe fresh air deeply.

　　The main symptoms of ascites include hypopituitarism, liver palms, cachexia, cyanosis, abdominal tenderness, peritonitis, ascites, enlargement of the liver and spleen, etc.

　　According to physical examination of ascites, in addition to mobile dullness, there are often signs of the primary disease. Ascites caused by heart disease can be seen with cyanosis, peripheral edema, distension of the jugular veins, enlargement of the heart, palpitations in the precordial area, enlargement of the liver and spleen, arrhythmia, and heart valve sounds during physical examination. Liver diseases often have dark or sallow complexion without luster, jaundice of the skin and sclera, spider veins on the face, neck, or chest, or liver palms, varicose veins on the abdominal wall, enlargement of the liver and spleen, etc. Ascites caused by kidney disease can have pale complexion, peripheral edema, etc. Flushed face, fever, abdominal tenderness, and softness of the abdominal wall may suggest tuberculous peritonitis. Patients with weight loss, cachexia, enlarged lymph nodes, or abdominal masses are mostly malignant tumors.

　　There is currently no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of the disease. Ascites that is common in clinical practice is caused by liver lesions. The following preventive measures should be taken for ascites caused by liver diseases.

　　1. Liver patients should pay attention to their daily diet, and patients must quit smoking and drinking.

　　Because the formaldehyde produced by the metabolism of alcohol in the body is very harmful to the liver. Liver patients themselves have damaged liver function, and drinking alcohol at this time is undoubtedly adding salt to the injury, accelerating the speed of disease progression, and is also very likely to form alcoholic liver disease.

　　2. Patients should also eat high-protein, high-vitamin, high-carbohydrate, and low-fat foods.

　　Because high-protein, high-vitamin, and high-carbohydrate foods can provide patients with sufficient energy, supplement the necessary substances in the body, reduce the consumption of the liver, alleviate the burden on the liver, and increase the power for liver cell repair and regeneration. Eating low-fat foods can also avoid patients developing fatty liver due to excessive intake of fat.

　　On the other hand, it can also reduce the consumption of liver cells and increase the recovery speed of liver cells.

　　3. Patients should adhere to a low-salt diet in their diet and adopt the method of small and frequent meals.In order to avoid increasing the burden on the body's digestive system, patients should choose easily digestible, high-fiber, low-spicy, non-irritating, and soft foods.

　　Because liver patients often have symptoms such as damaged or bleeding esophageal varices, consuming刺激性 or hard foods at this time may lead to the rupture of esophageal varices and cause massive bleeding.

　　4. Patients should strictly limit the intake of water and sodium, because a large part of the reason for the occurrence of ascites is the excessive retention of water and sodium in the body.If liver patients do not pay attention to this matter, it is easy to cause excessive retention of water and sodium in the body, leading to the occurrence of ascites. It is necessary to note that patients should pay attention to daily rest, establish a good rest and work schedule, and can also participate in appropriate exercise to relax the mind and body. In addition to the patient's daily diet, they should also visit the hospital in a timely manner. Only by completely curing the disease can it be the best way to prevent the occurrence of complications.

　　Laboratory examination is often an important means of discovering the cause. Liver function damage, hypoalbuminemia can suggest liver cirrhosis, large amounts of proteinuria, elevated blood urea nitrogen and creatinine levels suggest kidney function damage. Immunological examination is also of great significance for the diagnosis of liver and kidney diseases.

　　The examination of peritoneal fluid can determine the nature of ascites and differentiate the causes of ascites.

　　1. General examination

　　(1) Appearance: Exudate is usually pale yellow, thin and transparent. Transudate can be of different colors or turbid, depending on the etiology of ascites. For example, purulent infection presents as yellow purulent or purulent and hemorrhagic. Pseudomonas aeruginosa infection presents as green ascites, jaundice presents as yellow, and hemorrhagic ascites is seen in acute tuberculous peritonitis, malignant tumors. Chyle ascites presents as milky white and can coagulate, as it belongs to non-inflammatory products, it is still considered exudate.

　　(2) Relative density: The relative density of exudate is usually below 1.018, and the relative density of transudate is usually above 1.018.

　　(3) Coagulation: The exudate contains fibrinogen and thromboplastin released from the destruction of tissue cells, so it is prone to coagulate into clots or flocculent substances.

　　2. Biochemical examination

　　(1) Qualitative test of mucin: Exudate is negative, and transudate is positive. The quantitative exudate is less than 0.25g/L. The transudate is greater than 0.25g/L.

　　(2) Amylase level in pancreatic ascites is elevated.

　　(3) Bacteriological and histocytological examination: After centrifugation of ascites, the smear staining can detect bacteria, acid-fast staining can detect tuberculosis bacilli. Necessary bacterial culture or animal inoculation can be performed to detect tumor cells in ascites, which is very necessary for the diagnosis of abdominal tumors, with sensitivity and specificity up to 90%.

　　Other auxiliary examinations

　　1. Ultrasound and CT examination can not only show small amounts of ascites but also show the size, smoothness of the liver capsule, intraperitoneal space-occupying lesions, the size and structure of the heart, the inflow and outflow conditions of the heart, the blood flow conditions, the size, shape, and structure of the kidneys, etc.

　　2. Electrocardiogram examination can detect changes in heart rhythm and cardiac blood supply.

　　Suitable foods: The diet should be based on high calories, high protein, high vitamins, and moderate fat. Foods should be fresh, delicious, soft, and easy to digest, without irritation. Appropriate intake of foods rich in zinc and magnesium, such as lean pork, beef, mutton, fish, green leafy vegetables, peas, and dairy products.

　　Unsuitable foods: Avoid alcohol and smoking, limit the intake of certain foods high in sodium, such as pickled vegetables, noodles, fried dough sticks, shrimp skin, and avoid or eat less salted foods.

　　It is worth noting that patients with ascites should not undergo repeated fluid withdrawal, as repeated fluid withdrawal can lead to significant loss of nutritional proteins, causing serious damage to the immune system. After fluid withdrawal, the patient should receive Western medicine nutritional support therapy, combined with traditional Chinese medicine to strengthen the spleen and promote diuresis, enhance the function of transformation and transportation, so that ascites will no longer increase or inhibit its growth, and achieve the recovery of the patient's organ function and the improvement of immune function.

　　Because ascites patients have severe edema, daily health care should pay attention to protein supplementation, which is helpful for patient recovery.

　　Western medicine indicates: To treat ascites in this disease, there are mainly the following points.

　　1. Limitation of water and sodium intake: Ascites patients, especially those caused by hypoalbuminemia, should strictly control the intake of sodium, followed by water intake. The diet should be high in sugar, high in protein, high in vitamins, and low in fat, and low-sodium diet is also suitable for all patients with exudative or transudative ascites. The purpose is to excrete as much excess water as possible from the body through the kidneys.

　　2. Application of diuretics: Diuretics can be chosen to accelerate the excretion of water from the kidneys. Generally, potassium-sparing and potassium-wasting diuretics should be used together, or diuretics acting on different parts of the kidneys should be used together to achieve the best diuretic effect without causing electrolyte disorder (especially to prevent the increase or decrease of serum potassium ions).

　　3. Supplementation of albumin or acceleration of protein synthesis: If ascites is mainly caused by hypoalbuminemia leading to decreased plasma colloid osmotic pressure, in addition to eating more protein-rich foods, albumin should be appropriately administered intravenously to increase plasma colloid osmotic pressure. After albumin infusion, the diuretic effect of diuretics can be better exerted and urine output will increase significantly.

　　4. Treatment of ascites: When large amounts of ascites affect the patient's breathing or the patient has severe abdominal distension symptoms that are difficult to bear, treatment of ascites can be adopted to alleviate the symptoms.

　　5. Concentration and reinfusion of ascites, jugular vein return of ascites, or transjugular intrahepatic portal-systemic shunt (TIPS): If ascites is caused by decompensated liver cirrhosis portal hypertension and hypoalbuminemia, the method of concentrated ascites reinfusion can be adopted, that is, after ultrafiltration of ascites, the proteins, electrolytes, and other substances in the ascites are returned to the body through the jugular vein. Jugular vein return of ascites surgery is to insert a silicone tube from the peritoneal cavity along the abdominal wall and under the chest wall into the jugular vein, so that the ascites is drained into the jugular vein.

　　6. Application of vasodilators: When ascites is a transudate and large in volume with poor diuretic effect, vasodilators can be appropriately applied to improve renal blood supply, which is beneficial to enhance the diuretic effect.