STUDY - Technical - New Dacian's Medicine

Abdominal Distension and Ascites

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INTRODUCTION

Abdominal distention or abdominal enlargement is a common problem in medicine clinical and may be the initial manifestation of a systemic disease or an otherwise unsuspected abdominal disease. Distension abdominal se refers to the growth of abdominal circumference, the result of increased pressure intra-abdominal that forces the abdominal wall towards outside.

Distension can be mild or severe, depending on the actual pressure but also on the perceived by the patient. The pressure may be localized, or diffuse and can occur gradually or suddenly. Abdominal distention acute can signal life-threatening peritonitis or acute intestinal obstruction. Abdominal distention may also result from fat, flatus, an intra-abdominal meal (such as be an ectopic pregnancy) or liquid.

Fluids and gases are normally present in the gastrointestinal tract, but not in the peritoneal cavity. However, if fluids and gases cannot freely pass through the tract Gastrointestinal, abdominal distention occurs. In the cavity peritoneal, distention may reflect acute bleeding, accumulation of ascitic fluid or air by perforation of a abdominal organ.

Aggravating factors: food, medication, alcohol, movement, abdominal movements, position, emotional stress, in women correlations with the cycle menstrual.

Factors calming: food, especially milk, antacids, medication, alcohol, position, abdominal movements, gaseous transit, eructations (belching).

Subjective magnification of the abdomen, often described as a sensation of fullness or bloating is usually transient and is often related to a functional gastrointestinal disorder when not accompanied by objective physical signs of enlarged abdominal circumference, or local distention. Obesity and lumbar lordosis, which may be associated with abdominal protrusion, can usually be differentiated by real increases in the volume of the cavity peritoneal through historical and careful physical examination.

A general physical examination, carefully crafted, can provide valuable clues on etiology of abdominal distention. Thus, a palmar erythema and Stellate angiomas suggest an underlying cirrhosis, while supraclavicular adenopathy (Virchow ganglion) must raise suspicion of an underlying gastrointestinal neoplasia. Inspection of the abdomen is important. Observing the outline abdominal, it can differentiate the localized distention from the Generalized. Abdomen relaxed, in tension, with much skin stretched, with protruding flanks and navel relaxed is characteristic of ascites.

PHYSICAL EVALUATION

- It is observed the patient lying down if he shows abdominal symmetry to determine whether the distention is localized or generalized, including comparison with chest symmetry for displacements Asymmetric; it is observed if the skin is tense, shimmering, if the flanks are bulging, for identification of ascites; the shape of the abdomen may indicate signs of inguinal hernia (especially in men) or femoral, and deformations which may indicate adhesions; observe the navel which, if bent, may indicate ascites or umbilical hernia; an inverted navel may indicate gas distention and is, by also, frequently in obese patients, the skin may present skin rashes, bruises, jaundice, angiomatous "spider". Of also the pallor of the face is observed for the identification of hypovolemia, the presence of diaphoresis (profuse sweating) and, possibly the respiratory rhythm, which is increased but with Difficulties. Signs of recent accidents are being traced, or peritoneal bleeding (signs of Cullen or Turner).

- It will be checked the reaction to McBurney's point for the possible detection of a appendicitis.

- Palpation for determination of sensitivity gives clues as to localization or generalization, the abdomen being, in general, sensitive and rigid; on palpation to check the angle costovertebral; rubbing can give clues as to peritoneal inflammation and bruises may indicate an aneurysm; palpation gives clues as to the signs and symptoms peritoneal, such as sensitivity to return (to be retained place of pain), contracted areas or stiffness, size liver, the size of the aorta, including the presence of mass localized abdominal; in women, pelvic palpation reveals sensitivity of the appendages, pain when moving the cervix, uterine size and consistency, discharge of the cervix uterine, the presence of masses;

- Percussiongives indications of the distension resulting from the air, fluids or both. Sound tympanic in the lower right quadrant suggests descending colon or air-laden sigmoid. Then a tympanic note generalized suggests a peritoneal cavity filled with air. But in general, the timpania is "deaf", although a cavity full of fluid has the same type of tympany but they are made differentiations according to the existence of masses occurring on palpation, of some conformed diagnoses, such as ascites. In children, the eardrum is stronger (they swallow a lot of air when eat or cry) and the minimum timpania with abdominal distention may result from fluid accumulation or solid masses. Percussion can also be used in detecting liquid waves (especially ascitic), by percussion on the flank and referral liquid wave in the other flank or via "poodle sign" (patient placed on the elbows and knees, and percussion on the sidewall, median, starting from the basin to the diaphragm, sensing the level of fluid accumulation, ascitic or not);

- It will be checked and the femoral pulse where it is considered necessary.

- Rectally can Tenderness appears, masses and stool with blood may occur.

- Auscultation for intestinal sounds and percussion (if the sounds are not immediately perceived auscultation is recommended for a minimum of 5 minutes). Also, auscultation will be done after placing the patient in lateral decubitus, the sounds changing in the case of the possible presence of fluid in the peritoneal cavity (which moves gravitationally to the bottom).

- It can be done marking (using a marker) as a reference for subsequent measurements.

- Special tests are represented by: a. the "Psoas" test with lifting leg in hyperextension and lateral movement towards the hip noticing if this movement causes pain and b. test shutter in which the foot is flexed and rotated towards hip, noticing whether this movement causes pain.

DIAGNOSE

- Measure temperature, blood pressure (especially for hypotension status) and the pulse in the legs and stretched (of usually it is increased), the weight.

- The patient is asked about the onset, duration and signs and symptoms associated, such as pressure, fullness, difficulties Deep or stretched flat breathing and inability to se bend to the waist.

-Patient is asked about abdominal pain, fever, nausea, vomiting, anorexia, changes in intestinal habits and about weight gain or loss.

- It is reviewed medical history of the patient for interventions recent surgical and gastrointestinal disorders, or biliary that could cause peritonitis or ascites.

-Patient is asked about recent accidents, even those minor, such as falling off a ladder.

- The query regarding the explorations such as X-rays, barium enemas, series upper gastrointestinal, X-rays of the gallbladder, CT scan, sonographies or endoscopic procedures.

- It is addressed medical history of diabetes, heart disease arteriosclerotics (myocardial infarction or angina pectoris), arterial fibrillation, any surgical intervention abdominal (such as removal of the appendix), stones at kidneys, gallbladder disease, hiatus hernia, peptic ulcer, colitis, liver disease.

- Take in heredocolateral antecedental account on colitis, peptic ulcer, enteritis.

SPECIAL CONSIDERATIONS

-Obesity causes an "enlarged" abdomen with sensations of distention abdominal, without masses that can move, with mattity generalized rather than localized, with the intestine palpable, with protruding tympany.

- Overeating and constipation can cause distention Abdominal.

PEDIATRIC PECULIARITIES

- In children large, ascites usually result from heart failure, cirrhosis or nephrosis.

- A hernia can cause abdominal distention if it causes an obstruction Intestinal.

Custom, la many patients, the cause of abdominal pain is hard identifiable (has no clear "signs"), general perceptions being "centered" on gastroenteritis. However, irritable bowel and dyspeptic syndromes represent the cause of most chronic/ recurrent abdominal pain. Often there are distentions due to unconscious swallowing of air, in anxious people (localized in the right quadrant higher) or generalized distention following the consumption of fruits and vegetables with a high carbohydrate content non-absorbable, such as vegetables, or from fermentation their abnormality as a result of the action of microbes fermentatives.

CLINICAL SIGNS

From the point of view of clinical history, abdominal distention can be observed the patient's first time due to progressive increases in the size of clothing or belt, the appearance of hernias abdominal or inguinal or the development of a distention Localized. Often a considerable abdominal enlargement remained unnoticed for weeks or months, either due to obesity coexistent, either due to an insidious formation of ascites, no localized pain or symptoms. Abdominal distention progressive may be associated with a "pulling" sensation, or "stretching" of the flanks or inguinal region and a vague low dorsal pain.

Localized pain results usually from damage to an abdominal organ (for example, a congested passive liver, a splenomegaly or a tumor of colon). Pain is rare in cirrhosis with ascites, and when it is present, pancreatitis, carcinoma should be suspected hepatocellular or peritonitis. Ascites in tension or tumors abdominals can produce increased intra-abdominal pressure, causing indigestion and heartburn due to reflux gastroesophageal or breathlessness, orthopednea and tachypnea by lifting diaphragm.

A pleural exhaust coexistent, more frequently on the right side, probably due leakage of ascitic fluid through the lymphatic ducts in diaphragm, can also contribute to embarrassment Breath. The patient with diffuse abdominal distention should questioned about increased alcohol ingestion, an episode antecedent of jaundice or hematuria, or transit changes Intestinal. Such anamnestic information can provide clues that can lead to the suspicion of an occult cirrhosis, a tumor of colon with peritoneal metastasis, a heart failure congestive or a nephrosis.

An abdominal venous network protruding with drain direction departing from the navel it is often a reflection of portal (collateral) hypertension venous with outflow from the lower part of the abdomen to the navel suggests obstruction of the inferior cave vein and the flow from the upper part to the navel suggests the obstruction of the vein lower cave). Deformation in the "dome" of the abdomen with grooves visible data of the intestinal loops underneath is due to usually occlusion or intestinal distension. An epigastric mass, with obvious peristalsis, advancing from left to right, usually indicates underlying pyloric obstruction. A liver with Metastatic deposits may be visible as a nodular mass in the right hypochondrium, which moves with the breath.

Auscultation can reveal the precipitated, high-tone sounds of intestinal occlusion in the first phase or a clapping sound due to the increased quantity of liquid and gas in a dilated viscer. Careful auscultation above the enlarged liver sometimes highlights the harsh breath of a vascular tumors, in particular a hepatocellular carcinoma, or friction-like noise on the skin given by a nodule shallow. A venous murmur in the navel can signify portal hypertension and an increased collateral blood flow in around the liver.

Wave sign and mattity flanks moving with changing position the patient's are important signs that indicate the presence of fluid peritoneal. In obese patients, small amounts of fluid may be hard to highlight (sometimes the liquid can be detected by abdominal percussion with the patient resting on the hands and knees). Small amounts of ascitic fluid can often be detected only by ultrasound examination of the abdomen.

Careful percussion must contributes to the differentiation of a generalised increase in abdomen of localized distentions due to an enlarged uterus, an ovarian cyst or a relaxed bladder. Percussion it can also outline an abnormally small or large liver. Loss of normal liver matity may result from necrosis massive liver (may also be an indication of free gas in peritoneal cavity, as in the perforation of a cavitary viscera).

Palpation is often difficult in massive ascites and baling of the liquid they cover may be the only method of palpation of the liver or Spleen. A slightly enlarged spleen associated with ascites may be the only one sign of an occult cirrhosis. When there are signs of hypertension portal, a soft liver suggests that the obstruction of the portal flow is extrahepatic (a firm liver suggests cirrhosis as the most probable cause of portal hypertension). A very tough liver or nodular is an indication that the liver is infiltrated tumorally, and if accompanied by ascites, it suggests that it owes peritoneal sowing. The presence of a hard node periombilical (mother Mary Joseph's nodule) suggests a metastasis from a primary pelvic or gastrointestinal tumor.

A pulsating liver with ascites may be encountered in Tricuspid insufficiency. It must be done an attempt to determine whether a mass is solid or cystic, smooth or irregular and if it moves with breathing. Liver the spleen and gallbladder should go down with the breath, if they are not fixed by adhesions or extension of a tumour beyond the organ. A fixed mass that does not go down with the breath may indicate an inflammatory process, such as an abscess (it may also due to a distention of the visceral peritoneum or necrosis tumor). Rectal examination and pelvic examination are mandatory (they may reveal otherwise undetectable masses due to a tumor or infections).

Radiographic and radiographic examinations laboratory are essential to confirm or complete impressions acquired at the physical examination. Abdominal clichés in clino and orthostatism can reveal dilated intestinal loops, with liquid levels characteristic of intestinal occlusion, or diffuse abdominal veil and erasure of the edge of the psoas, suggestive of ascites. Ultrasound is often valuable in detection of ascites, in determining the presence of a mass, or evaluation of liver and spleen sizes. Computed tomography computerized (TC) provides similar information.

TC scanning is often necessary to view the retroperitoneal region, pancreas and lymph nodes. A simple X-ray of the abdomen can reveal the relaxed colon from a colitis otherwise unsuspected ulcerative and can give valuable information on the size of the liver and spleen. A hemicupola irregular and elevated right diaphragmatic can be a clue for a liver abscess or hepatocellular carcinoma. Investigations of the gastrointestinal tract with barium or other Contrast substances are usually required in search of a primary tumors.

From a point of view of the "signs" with pain, we are dealing with:

1. Pain acute abdominals dangerous for survival, attracted by:

a. Peritonitis (including perforation of the viscera): severe pain and generalized with contraction, rigidity and sensitivity to recovery, decreased intestinal sounds, prostration (the patient lies motionless, the pain worsening when moving), fever / chills, hypotension, tachycardia may be present, pallor and sweating;

b. Myocardial Intestinal: occurs especially at the age of over 50 years (with unless the arterial embolus is the factor causal), the pain is often diffuse and may not touch maximum intensity for hours, diarrhea with occasional blood, hypotension, tachycardia, pallor and may also be present sweating, including signs of peritonitis;

c. Obstruction intestinal: nausea. vomiting, often a previous history of constipation, a history of abdominal surgery, pain is oscillating, generalized tympanic percussion with loud sound in the side of the obstruction ascending and decreasing downwards obstruction, the agitated patient frequently turning off a side on the other side;

d. Rupture of a abdominal aortic aneurysm: acute abdominal, lumbar pain or in the flank, pulsatile abdominal mass, may be present hypotension, tachycardia and asymmetrical pulse;

e. infarction Myocardial: severe epigastric discomfort (most often at people over 50 years of age, women and diabetics), nausea and occasional vomiting, diaphoresis (profuse sweating), and lack of abdominal sensitivity.

Note: Identifying the signs described above requires measures of emergency: travel to an emergency hospital, placement in lying position, administration of oxygen and administration intravenous fluids, etc. It is possible the appearance of the requirement of insert nasogastric tube for possible distention acute intraluminal. Many times it will come to treatments extensive, lasting, including surgery, there where appropriate.

2. Pain Acute abdominal attracted by:

a. Gastroenteritis: nausea and vomiting frequently accompanied by diarrhea, diffuse, mild, cramping, abdominal pain, muscle aches and fever mild, occasionally may follow the ingestion of food contaminated, possible abdominal sensitivity to palpation;

b. Appendicitis: initially the pain is epigastric/ periombilical, often progressing to the right lower quadrant (which becomes sensitive to abdominal or rectal examination), with gradual onset of what progresses over the hours, mild fever, the intestine rings variable, peritonitis may occur if perforation occurs, shutter tests/ Psoas are often positive, sensitivity of return to the lower right quadrant; c.

Hepatitis: state of bad, myalgia, nausea and pain in the right upper quadrant, sensitivity and enlargement of the liver, jaundice may be present;

d.Diverticulitis: sensitivity, fullness, mass and/or pain in the quadrant bottom left, constipation, nausea, frequent vomiting that lasts several days, the decrease in the sounds of the intestine, can be localized signs of peritonitis present, 25% of patients may present minor rectal bleeding (including rectal mass occasional and tenderness);

is. Cholecystitis: cholicous pain in the epigastrium or in the right upper quadrant with a tendency to "protection", which occasionally irradiates to right scapula, colic with nausea, vomiting, fever, sometimes chills, jaundice, dark urine, colored stools open (obstruction of the common channel) can be recurrent with occasional comeback;

f. Pancreatitis: upper abdominal pain (mild to severe), irradiated occasionally towards the back, often recurrent, which can be relieved by setting up or tilting forward, associated with nausea/ vomiting, a history of alcoholism or calculi biliary, periumbilical sensitivity, occasional associations with hypotension, tachycardia, pallor and sweating, decrease sounds of the intestine;

g. Disease pelvic inflammatory of salpingitis (in women): initial pain in the lower quadrants that can be generalized (with a tendency of "protection"), usually severe, pain when moving the side of the cervix, tenderness of appendages, fever/chills occasionally dyspareunia (violent pain during the act sexual), occasional vaginal discharge (often purulent);

h. Load ruptures ectopic (in women): the last menses with more than 6 weeks before, pain in a lower quadrant, acute and severe onset, sensitivity and annex mass, hypotension may be present postural and tachycardia;

i. Stones Ureteral: the pain can begin in the flank and can irradiate in inguinal area, can highlight a history of kidney stones, painful urination and blood in the urine are often observed;

j. Prostatitis: change in the rhythm of urination, painful urination, pain lower abdominal, "soft" prostate.

3. Pain Chronic abdominal / recurrent attracted by:

a. Reflux esophageal: burning, epigastric or substernal pain that irradiates to the jaw, worsens in the stretched posture or bent, especially shortly after eating, improves at administration of antacids or in vertical posture, occurs in especially in obese patients;

b. Peptic ulcer or dyspepsia (nonulcerative): burning or irritation, deep epigastric tenderness, epigastric pain localized or recurrent that occurs 4 hours after meals, perhaps be aggravated by the consumption of alcohol, aspirin, steroids or other anti-inflammatory drugs, improve when drinking antacids or food;

c. Colitis ulcerative: rectal tenderness, tenderness of the colon, recurrent defecation of small amounts of semiformed stool, the pain worsens even before bowel movements, frequent blood in the stool, mild fever, may be present weight loss;

d. Enteritis regional: tenderness and pain in the right lower quadrant or periumbilical (including periumbilical mass), usually at young, insidious onset, can be relieved by defecation, the stools are often soft and unformed, mild fever, perhaps weight loss occurs;

is. Colon irritable: recurrent abdominal discomfort and/or changes in intestinal habits aggravated by anxiety, diarrhea often alternates with constipation, being a syndrome predominantly, minimal abdominal tenderness during large intestine.

ASCITES

Evaluation of the patient with ascites need to be established the cause of ascites. In the most Many cases, ascites will appear as a part of a disease recognized, i.e. cirrhosis, congestive heart failure, nephrosis or disseminated carcinomatosis. In these situations the doctor must determine whether the appearance of ascites is indeed a consequence of the underlying disease and is not due to the presence of a separate or related process. This distinction is required even when the cause of ascites seems obvious.

For example, when the patient with compensated cirrhosis and minimal ascites develops progressive ascites which is increasingly difficult to control with a salt-free regimen or diuretics, the greatest temptation is to attribute the aggravation clinical picture of progressive liver disease. However, a carcinoma occult hepatocellular, a thrombosis of a portal vein, peritonitis bacterial or even tuberculosis may be responsible for decompensation. Disappointingly low success of diagnosis tuberculous peritonitis or hepatocellular carcinoma at the patient with cirrhosis and ascites reflects the too low index of suspicion of the development of such over-added diseases. Similarly, the patient with congestive heart failure may do ascites due to a disseminated carcinoma with metastasis Peritoneal.

Diagnostic parecentesis (50-100 ml) must be part of the routine evaluation of the patient with ascites. The liquid must be examined macroscopically (protein content, number of cells must be determined, and differentiated cell count and Gram dyes, and for acid-alcohol-resistance germs and must be achieved crops). Cytological examinations and cell blockage may it revealed an otherwise unsuspected carcinoma. From the point of view of characteristics of ascitic fluid, in some disorders, how is cirrhosis, the liquid has the characters of a transsudate (less of 25 g of protein per liter and a density below 1016) and in other disorders has the characteristics of an exudate.

Some authors prefer use, instead of the total protein content of the liquid of ascites, the gradient of albumin between plasma and ascites (GAPA) for the characterization of ascites. The gradient correlates directly with portal pressure. A gradient greater than 1,1 g/dl, is characteristic of uncomplicated cirotic ascites and a gradient sun 1,1 g/dl is found in characterized diseases of exudative ascites. Although there is a variability of the liquid of ascites in any pathological condition, some properties are characteristic enough to suggest certain possibilities Diagnostics.

For example, the liquid hemorrhagic with more than 25 g protein per liter is unusual in uncomplicated cirrhosis, but is compatible with a peritonitis tuberculous or a neoplasm. Cloudy liquid with predominance polymorphonuclear cells and positive to Gram staining is characteristic of bacterial peritonitis (if most cells are lymphocytes, tuberculosis should be suspected). The complete examination of each collection of liquid is very important, because sometimes only one result can be abnormal.

For example, if the liquid is a typical transudate, but contains more than 250 leukocytes/ mm cube, this result must be recognized as atypical for cirrhosis and must cause the search for a tumor or Infections. This is especially true when evaluating Cirrhotic ascites, in which occult peritoneal infection can be present only at small increases in the number of leukocytes in peritoneal fluid (300-500 cells/ cubic mm).

Because the Gram coloration has the liquid can be negative in a large proportion of such cases, culture of the peritoneal fluid is mandatory. Sowing at the bedside of the sick person the culture vial of blood with ascitic fluid leads to a dramatically increased incidence of positive cultures when bacterial infection is present (90 compared to 40% positive crops in conventional cultures made laboratory). Direct view of the peritoneum (laparoscopy) can reveal tumor peritoneal deposits, tuberculous, or conditions with liver metastasis. Biopsies it is performed under direct visual control, often increasing the diagnostic accuracy of the procedure.

Ascites tickle designate a turbid, milky or creamy peritoneal fluid due to the presence of thoracic or intestinal lymph. Such a liquid presents fat globules on microscopic examination with Sudan staining and an increased triglyceride content on chemical examination. The opaque milky liquid usually has a concentration of triglycerides above 1000 mg/ dl. A turbid liquid due Leukocytes or tumor cells can be confused with chilos fluid (pseudokylos) and often it is useful performing alkalization and ether extraction of the sample.

Alkaline substances will tends to dissolve cellular proteins and therefore decrease turbidity (extraction with ether will lead to clarification if turbidity of the liquid is due to lipids). Ascites cylinder head is most often the result of lymphatic obstruction caused by trauma, tumors, tuberculosis, filariasis, or congenital anomalies. It can also be found in nephrotic syndrome.

Rarely, the fluid of ascites has a mucoid appearance, suggesting either peritoneal pseudomygus or rarely a colloid carcinoma of the stomach or colon with peritoneal metastases. Sometimes ascites can occur apparently isolated in the absence of a clinically obvious underlying disease. In these conditions, a careful analysis of the fluid of ascites can indicate the direction in which the assessment should be directed. A Useful scheme of investigation begins by analyzing whether the liquid is transudate or exudate.

Transsudative ascites of Unclear etiology is most often due to a cirrhosis occult, a straight vein hypertension increasing the pressure sinusoids of the liver, or hypoalbuminemic states like nephrosis or enteropathy with loss of protein. Cirrhosis with well-preserved liver function (normal albumin) that produces Ascites is invariably associated with portal hypertension Significant. The assessment must include function tests liver, hepatosplenic tomography or other procedures hepatic visualization (i.e. CT or ultrasound) to detect intrahepatic nodular changes or a colloidal displacement of isotopes suggesting portal hypertension.

Sometimes a venous pressure Blocked liver can be useful to prove hypertension portal. Finally, if clinically indicated, a biopsy the liver will confirm the diagnosis of cirrhosis and may suggest its etiology. Other etiologies can cause venous congestion liver and consecutive ascites. Valvular disorders of the right heart and especially constrictive pericarditis must present a high degree of suspicion and may require techniques cardiac imaging and cardiac catheterization for diagnosis definitively. Thrombosis of the hepatic vein is evaluated by visualization of the hepatic veins using imaging techniques (Doppler ultrasound, angiography, CT, MRI) to demonstrate obliteration, thrombosis or obstruction by tumor. Rarely Transsudative ascites may be associated with benign tumors of the the ovary, especially fibroids (Meigs syndrome) with ascites and hydrothorax.

I'll finish this post with a few elements about exudative ascites. It must initiate an investigation for primary peritoneal processes, of which the most important are infection and tumors. Routine bacteriological cultures of ascitic fluid will frequently designates a certain microorganism that causes peritonitis Infectious. Tuberculous peritonitis is best diagnosed by peritoneal biopsy, percutaneous or by laparoscopy. Histological examination invariably shows granulomas that may contain acid-alcohol-resistant bacilli.

Because the liquid cultures Peritoneal and tuberculosis biopsies may require 6 weeks, characteristic histology with appropriate staining allows prompt start of antituberculosis treatment. Similarly, the diagnosis of tumor insemination of the peritoneum can usually be done by cytological analysis of the liquid peritoneal or by peritoneal biopsy if the cytology is Negative. Appropriate diagnostic investigations can be performed to determine the nature and location of the primary tumor.

Pancreatic ascites is invariably associated with an extravasation of pancreatic fluid from the canalicular system of the pancreas, most commonly through leakage from a pseudocyst. Ultrasonic or TC examinations of the pancreas followed by visualization of the pancreatic duct through direct cannulas (endoscopic cholangiopancreatography retrograde, CPER) will usually discover the location of the leak and will allow resection surgery to be performed. An analysis of the physiological and metabolic factors involved in production of ascites, associated with a full assessment of nature ascitic fluid will invariably discover the etiology of ascites and will allow for the establishment of appropriate treatment.

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Dorin, Merticaru