Hepatic ascites

　　The most common cause of ascites is liver cirrhosis, especially alcoholic liver cirrhosis. Other etiologies include chronic hepatitis, severe alcoholic hepatitis without liver cirrhosis, and portal vein thrombosis due to hepatic vein obstruction (Budd-Chiari syndrome). Ascites will not occur unless there is concurrent liver dysfunction. Non-hepatic etiologies of ascites include systemic diseases (such as heart failure, nephrotic syndrome, severe hypoalbuminemia, and restrictive pericarditis) causing general body fluid retention and intra-abdominal diseases (such as cancer and tuberculous peritonitis). Hypothyroidism occasionally causes significant ascites, and pancreatitis rarely causes large amounts of ascites (pancreatic ascites). Renal failure patients, especially those undergoing hemodialysis, occasionally develop unexplained ascites (renal ascites).

　　1. Portal hypertension:The portal vein and inferior vena cava, also known as the portocaval vein, are the connecting points between the liver and the rest of the blood circulation. It is also the only way for the hepatic artery and hepatic vein to enter and exit. Under normal circumstances, the capacity of the arterial and venous vascular beds is basically equal, and the input and output blood flows are in a balanced state.

　　In liver cirrhosis, due to the alteration, necrosis, and fibrous tissue proliferation of liver cells, the intrapulmonary vascular bed is compressed, twisted, deformed, and narrowed, blocking the blood vessels, causing sinusoidal congestion and a significant decrease in blood flow. The input is significantly greater than the output, leading to increased portal caval pressure. At the same time, the venous pressure of the capillaries also increases. Over time, the blood return from the gastrointestinal tract, mesentery, peritoneum, and other blood vessels is obstructed, the vascular permeability increases, and the plasma components in the blood leak out, forming ascites.

　　2. Hypoproteinemia:This is due to the fact that the liver cannot synthesize albumin from the nutrients absorbed and digested by the gastrointestinal tract. Due to the decrease in serum albumin, the colloid osmotic pressure in the blood vessels decreases, causing the plasma components to leak out and form ascites.

　　3. Endocrine disorder:During active liver cirrhosis, due to the greatly reduced inactivation of antidiuretic hormone by the liver, its content increases, leading to decreased urine output and causing edema and ascites.

　　4. Lymphatic return obstruction:The human lymphatic circulation is also known as the third circulation, referring to a circulatory system located outside the arteries, veins, and capillaries. Normally, there is no place without lymphatic circulation, especially between the hepatic sinusoids and liver cells, where there is abundant lymph fluid. Due to the lesion, the liver not only increases the portal caval pressure but also increases the lymph pressure, expands the lumen, impairs lymphatic return, causes lymph fluid to leak out, and forms ascites.

　　When suffering from hepatic ascites, severe complications may include hepatic encephalopathy, massive bleeding from the upper gastrointestinal tract, biliary tract infection, bronchitis, primary liver cancer, hepatorenal syndrome, portal vein thrombosis, changes in hepatic and extrahepatic vascular structures, refractory ascites, and other complications.

　　Ascites tends to exist in a long-term (chronic) form rather than a short-term (acute) episode, and it most frequently occurs in liver cirrhosis, especially alcoholic cirrhosis. Small amounts of ascites usually do not cause symptoms, but large amounts of ascites can cause abdominal distension and discomfort, shortness of breath, and a dull sound on percussion by the doctor. Large amounts of ascites can lead to abdominal tension or prominence. Some ascites patients have joint swelling (edema) due to excessive water content.

　　1. Pre-ascites stage of liver cirrhosis:At this time, cirrhotic patients have no ascites and no expansion and insufficiency of systemic arterial circulation, but excessive intake of sodium salts can cause water and sodium retention, indicating that the kidney's processing of sodium has been impaired at this time. This is due to the liver dysfunction and increased portal vein pressure affecting the kidney's processing of sodium salts through direct neural reflexes, but this water and sodium retention is self-limiting.

　　2. Reactive cirrhotic ascites stage:The obvious increase in renal sodium and water retention leads to an expansion of total blood volume, followed by the expansion of peripheral arteries to reduce vascular resistance. The expansion of peripheral arteries is due to the release of a large amount of various vasodilatory substances by visceral tissues, thereby causing the visceral and systemic circulations to expand sequentially. Subsequently, according to the peripheral artery hypothesis, ascites is formed.

　　3, Refractory liver cirrhosis ascites stage:During this stage, patients have severe liver disease, obvious sodium and water retention, are insensitive to diuretic treatment, and have unstable hemodynamics. The activity of the renin-angiotensin-aldosterone system and the sympathetic nervous system is hyperactive, and the peripheral vessels have a reduced responsiveness to vasoactive substances. However, renal vessels are very sensitive to vasoconstrictors, and the kidneys further increase sodium reabsorption while reducing excretion, resisting the effects of diuretics and natriuretic factors.

　　4, Liver-kidney syndrome stage:This stage often occurs in decompensated liver cirrhosis patients with refractory ascites. Due to further peripheral arterial dilation, low blood pressure occurs, and the body, in order to maintain effective blood volume, causes the synthesis of vasoconstrictive substances to increase, especially the increase of plasma endothelin levels. Due to the high sensitivity of renal vessels to vasoconstrictive substances at this time, it leads to selective renal hypoperfusion, severe sodium and water retention, and renal failure.

　　Ascites of the liver generally arises from liver cirrhosis, which is one of the most significant complications of liver cirrhosis. Its appearance represents the liver function entering the decompensation stage. Therefore, effectively preventing the occurrence of liver ascites is a very important measure to save the patient's life and health.

　　Firstly, liver cirrhosis patients should pay attention to their daily diet. Patients must quit smoking and drinking, as the alcohol in wine is metabolized into formaldehyde, which is very harmful to the liver. Liver cirrhosis patients already have damaged liver function, and drinking alcohol at this time is undoubtedly adding salt to the injury, accelerating the progression of the disease, and is also prone to the development of alcoholic liver disease.

　　In addition, patients should consume high-protein, high-vitamin, high-carbohydrate, and low-fat foods. High-protein, high-vitamin, and high-carbohydrate foods can provide sufficient energy for patients, supplement the necessary substances in the body, reduce liver consumption, alleviate the burden on the liver, and increase the power for liver cell repair and regeneration. Eating low-fat foods can not only prevent patients from developing fatty liver due to excessive intake of fat but can also reduce the consumption of liver cells and improve the recovery speed of liver cells. In addition, patients should adhere to a low-salt diet in their diet and adopt the method of eating small and frequent meals to avoid increasing the burden on the digestive system. Patients should choose easily digestible, high-fiber, low-spicy, non-irritating, and soft foods because liver cirrhosis patients often have symptoms such as esophageal variceal injury or bleeding. In this case, eating刺激性 or hard foods may lead to the rupture of esophageal varices and massive bleeding.

　　Patients should strictly limit their intake of water and sodium. A significant part of the cause of ascites is the excessive retention of water and sodium in the body. If liver cirrhosis patients do not pay attention to this, it is easy to lead to excessive retention of water and sodium in the body, causing the appearance of ascites. It is important 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 relieve stress and improve mental well-being.

　　In addition to preventive measures in daily diet, chronic hepatitis is also a major cause of liver cirrhosis. Chronic hepatitis is often overlooked due to its不明显 symptoms, leading to persistent viral infection and the development of liver cirrhosis.

　　Due to individual physique and symptoms of ascites patients, specific examination items should still be determined according to the degree of the disease, as follows:

　　1. Alpha-fetoprotein (AFP) test:Electrophoresis method positive or radioimmunoassay determination >400mg/ml; continuous for four weeks and exclude pregnancy, active liver disease, and germ cell embryonic tumors.

　　2. Other marker tests:Alkaline phosphatase about 20% of liver cancer patients increased γ-glutamyl transpeptidase (γ-GT) most liver cancer patients increased 5-nucleotidase isoenzyme V (5-PDase-v) xq most patients have this enzyme in metastatic liver cancer patients with a higher positive rate α-antitrypsin (α-AT) about 90% of liver cancer patients increased elastase 905 liver cancer patients increased the content of carcinoembryonic antigen (CEA) 70% of liver cancer patients increased abnormal prothrombin greater than 300mg/ml.

　　3. Liver function and hepatitis B antigen antibody system examination:Abnormal liver function and positive hepatitis B markers suggest a liver disease foundation with primary liver cancer.

　　4. Various imaging examinations:Indicates intrapulmonary space-occupying lesions.

　　5. Laparoscopy and liver puncture examination:Laparoscopy can directly show the condition of the liver surface; liver puncture biopsy.

　　Patients with ascites due to liver disease should eat more fresh vegetables and fruits rich in vitamins. Bananas are rich in potassium ions, and eating more appropriately can supplement potassium lost due to the use of diuretics. Various meats, fish, and eggs can be eaten, which is beneficial for the absorption of nutrition. However, finished and semi-finished dishes sold in the market should not be eaten due to high salt content. It is not advisable to eat soy products, and rough, cold, red, and acidic or alkaline foods should be avoided, and small mouthfuls should be swallowed. The total amount of water ingested by the patient each day (including tea, soup, and medicine) should not exceed 1 liter to control the growth of ascites and correct hyponatremia.

　　The treatment of ascites due to liver disease in traditional Chinese medicine should be selected according to the patient's symptoms, as follows:

　　1. Qi stagnation and dampness obstruction

　　Symptoms: Abdomen is large and distended, it is not firm when pressed, blue veins under the abdomen are exposed, both sides of the ribs are painful, appetite is poor, distension occurs after eating, limbs are weary, urine is short and less. Tongue coating is white and greasy, pulse is wiry and slippery.

　　Treatment principle: Soothe the liver and regulate qi, and strengthen the spleen to remove dampness.

　　Bupleurum formula: Bupleurum舒肝散 combined with Weiling Decoction with modifications, including Bupleurum, Citrus reticulata peel, Cyperus rotundus, White peony root, Citrus reticulata peel, Chuanxiong rhizome, Magnolia officinalis bark, Atractylodes macrocephala, Alisma orientale, Poria, Pericarpium arecae, Cinnamon.

　　2. Qi stagnation and blood stasis

　　Symptoms: Abdomen is large and firm, blue veins are exposed, mass under the ribs is painful, complexion is dark, skin has thread-like blood spots, palm has red stains, mouth is dry and thirsty, but wants to rinse the mouth but not want to swallow, stool is black, lips are purple and dark, tongue is purple and dark or has spots, sublingual veins are varicose. Pulse is thin and涩.

　　Treatment principle: Promote blood circulation and remove blood stasis, and promote diuresis and reduce swelling.

　　Herbal medicine: Tiaoying Decoction with modifications, including Angelica sinensis, Peony root, Chuanxiong rhizome, Yuanhu bulb, Ophiopogon japonicus, Semen spatholobus, Rhubarb, Equisetum hyemale, Poria, Pericarpium arecae, Prunus persica leaf, Citrus reticulata peel, Carthamus tinctorius.

　　3. Damp-heat Accumulation

　　Symptoms: Abdominal distension and fullness, abdominal and epigastric pain and distension,烦热口苦, thirsty but not willing to drink, reddish urine, constipation, red tip and edge of the tongue with yellow greasy fur, wiry and rapid pulse.

　　Therapeutic Principle: Clear heat and drain dampness, attack and expel edema.

　　Herbal Medicine: Zhongfen Fenxiao Pill combined with Yinchenhao Decoction, prepared according to the formula, Scutellaria baicalensis, Coptis chinensis, Magnolia officinalis, Pericarpium Citri reticulatae, Atractylodes macrocephala, Pinellia ternata, Poria, Alisma orientale, Zizyphus jujuba, Rheum palmatum, Gardenia jasminoides.

　　4. Cold and Dampness Invading the Spleen

　　Symptoms: Abdominal distension and fullness, as if it is wrapped in a bag of water, chest and epigastrium fullness and stuffiness, slightly relieved with heat, fatigue, aversion to cold and laziness, oliguria, loose stools, white greasy tongue fur, slow pulse.

　　Therapeutic Principle: Warm the middle-jiao and transform dampness.

　　Herbal Medicine: Shisui Decoction, prepared according to the formula, Poria, Atractylodes macrocephala, Magnolia officinalis, Pericarpium Citri reticulatae, Moschus moschatus, Cinnamon, Zingiber officinale, Citrus reticulata, Citrus aurantium.

　　5. Spleen and Kidney Yang Deficiency

　　Symptoms: Abdominal distension, more severe in the evening, not firm to control, accompanied by dim complexion, aversion to cold and cold limbs, fatigue, oliguria and loose stools, or edema in the lower limbs, pale and bloated tongue with thin white greasy fur. Deep, fine, and weak pulse.

　　Therapeutic Principle: Warm and invigorate the Spleen and Kidneys, transform Qi and promote water flow.

　　Herbal Medicine: Jisheng Shenqi Pill, prepared according to the formula, Rehmannia glutinosa, Fructus Corni, Rhizoma Alismatis, Poria, Aconitum carmichaelii, Cinnamon, Plantago asiatica, Poria, Astragalus membranaceus.

　　6. Kidney and Liver Yin Deficiency

　　Symptoms: Abdominal distension and fullness, in severe cases, blue veins exposed, emaciated body, yellowish or dark face and purple lips, dry mouth and heart palpitations, hot palms and soles, oliguria and dark, short stool, constipation, or epistaxis and nosebleeds. Red tongue with less fur and a wiry and thready pulse.

　　Therapeutic Principle: Nourish the Liver and Kidneys, Cool Blood and Dissolve Stasis.

　　Herbal Medicine: Gansui Decoction combined with Xuefu Zhuyu Decoction, prepared according to the formula, Rehmannia glutinosa, Schisandra chinensis, Ophiopogon japonicus, Melia toosendan, Angelica sinensis, Chuanxiong, Radix Paeoniae Rubra, Corydalis yanhusuo, Prunus persica, Carthamus tinctorius.

　　7. Deficiency of both Qi and Blood

　　Symptoms: Dizziness and palpitations, pale complexion, fatigue, lack of appetite, hidden pain in the flanks, pale tongue with thin white fur, weak pulse.

　　Therapeutic Principle: Invigorate Qi and Blood with herbal medicine,补血益气复肝汤:Radix Pseudostellariae, Astragalus membranaceus, Polygonum multiflorum, Poria, Fried Atractylodes macrocephala, Angelica sinensis, Colla Corii Asini, Salvia miltiorrhiza, Curcuma wenyujin, Moschus moschatus, Forsythia suspensa, Mulberry.

　　That's all about the introduction of how traditional Chinese medicine treats ascites of liver cirrhosis. After knowing the medicine for treating liver and abdominal dropsy in traditional Chinese medicine, the editor suggests that you choose a suitable traditional Chinese medicine treatment method according to your symptoms under the guidance of a doctor.