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Ascites precox

Posted Aug 28 2010 10:48am

Fluid retention is  a classical sign  of  cardiac failure . (Elevated JVP, hepatomegaly , edema legs ) The mechanism of fluid retention are many .But, traditionally we have given importance to   venous back pressure  (Hydrostatic pressure)  . Equally important (if not more !) is the renal sodium  and  fluid  conservation  in response to reduced effective renal blood flow.

How common is ascites in cardiac failure ?

While we see hydrothorax  little  more frequently  it is rare to  get ascites in cardiac failure .However ascites often manifests late  in the pre terminal phase of cardiac failure *. This is due to congestive hepatomegaly, secondary hyperaldosteronism and renal dysfunction .

When does ascites come early before edema of extremities in cardiac failure ?

It is  classically  reported in in constrictive pericarditis. The reason why ascites precedes edema legs is  long  been speculative . Now we have evidence , the pericardial pathology , has a direct effect on the hepatic venous morphology. There can be a  selective  , partial constrictor effect on at least one of the hepatic vein as it enters the right atrium .In fact , the entry point of hepatic vein is  delicately  close to IVC/RA junction.

*It should be remembered in the current era we are expected to diagnose cardiac  failure even before  the onset of edema !

Anatomical   constriction has a mechanical effect on the hepatic venous drainage  and subsequently alters the hepatic function . Segmental hepatic dysfunction is thought to  ooze out the   ascitic fluid  from the surface of liver .Ultimately severe raise of hepatic venous pressure results in congestive hepatomegaly and could result in now obsolete , cardiac cirrhosis.

Other mechanisms of ascites  in constrictive pericarditis , include

  • Hypoprotenimia
  • Common infection of  peritoneum and pericardium( like tueberculosis)

Is ascites precox an exclusive feature of constrictive pericarditis ?

Not necessarily so  . Even though , it was first described in this condition ,clinical experience  suggest, any  congestive cardiac failure with predominate right sided  pathology like organic tricuspid valve stenosis or regurgitation, right ventricular  endomyocardial  fibrosis  , all can result in significant ascites which may precede edema  legs.

What is  effect of  of severe TR on hepatic venous  hydrodynamics ?

TR like MR  can be eccentric and some times hits upon  the hepatic veins directly

and result in disproportionate elevation of hepatic venaous presure than even IVC pressure

which  may contribute to early ascites in organic tricuspid valve disease.


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