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Abdominal fluid accumulation

Abdominal fluid accumulation indicates the onset of a medical condition called ascites. Ascetic fluid is a pale yellow colored fluid. The predominant accumulation of ascetic fluid occurs in the region of peritoneum. Ascetic fluid has many sources. However the most significant source is the liver. One of the major causes for ascites is liver cirrhosis.


Abdominal fluid accumulation

Causes for accumulation of ascetic fluid

The factors contributing to liver cirrhosis are associated with portal hypertension and edema caused because of tissue fluid imbalance or infection. The formation of ascetic fluid is also associated with the decrease in albumin levels. Albumin levels are decreased in portal hypertension conditions. Another significant factor that leads to accumulation of ascetic or abdominal fluid is the underlying condition of kidney failure caused due to excess salt and water retention. In addition, ascetic fluid accumulation is also caused because of underlying conditions such as neoplasm, congestive heart failure and infectious diseases such as tuberculosis. Ascetic conditions are classified into transudative and exudative types based on the protein estimation of the respective ascetic fluid. The comparative analysis of protein in the ascetic fluid is based on the albumin levels in the ascetic fluid when compared to serum albumin. This comparative analysis is also called as serum ascites albumin gradient.


Symptoms of abdominal fluid accumulation

Ascetic symptoms are associated with abdominal pain and discomfort. In some cases the ascetic condition is initially asymptomatic which progresses into a symptomatic condition. Shortness of breath occurs because of pleural effusion which is caused by the pressure on diaphragm because of the abdominal fluid rise. Apart from these other symptoms are nausea, anorexia, and bloating and flank pain.


Conditions associated with abdominal fluid accumulation such as ascites are diagnosed using laboratory analysis. Laboratory tests such as ascetic fluid protein estimation, albumin analysis, amylase, lactose dehydrogenase and triglyceride values are taken into consideration. These values help in the determination of underlying conditions which may be responsible for the accumulation of ascetic fluid in the abdominal cavity.


Microbiological analysis such as Gram's stain, acid fast stain and also cultures of both routine bacteriology and for Mycobacterium is done to diagnose the condition due to of infectious diseases. In the case of tuberculosis, the ascetic fluid tends to appear chylous or milky in nature. This because of the presence of thoracic or interstitial fluid. The serum ascites albumin gradient values are taken into consideration to determine the cause of ascites because of bacterial peritonitis, Pancreatitis, Vasculitis and portal hypertension. High albumin gradients or transudative gradients generally occur in unclear etiologies such as occult cirrhosis and portal hypertension. Hepatic vein thrombosis and liver cirrhosis related ascites is generally diagnosed by biopsy and radiological methods.


Treatment of abdominal fluid accumulation

Ascites is treated according to fluid electrolyte monitoring. The patient is prescribed a restricted salt diet in order to avoid edema. In cases of low sodium levels, the salt restriction may be increased to 1.5 l instead of 1. Diuretics are generally prescribed in the case of ascites. The research pertaining to the use of aquaretics for the excretion of electrolyte free water is still underway for the approval.

Therapeutic paracentesis is administered on a regular basis to treat refractive ascites. The most effective method for reducing the portal pressure in patients with ascites and under diuretics is the administration of trans jugular intrahepatic portosystemic shunt also known as TIPS. This is a radiological procedure used in patients suffering from refractive ascites; this technique may be performed either in conscious state or by administering general anesthesia.

Cirrhosis

The liver is responsible for neutralizing the blood of toxins, germs and bacteria as well as producing immune agent to control infections. Bile, critical to the absorption of fats and fat-soluble vitamins is made by the liver. Cirrhosis is a condition where the liver is affected by irreversible scar tissue leading to its damage and consequent failure. Blood flow to the liver is then affected. Symptoms of cirrhosis range from exhaustion and fatigue to weight loss and abdominal pain. A person suffering from liver cirrhosis may experience abdominal pain and loss of appetite. There are noticeable red spider veins under the skin and the skin and eyes may turn yellow. There is decreased interest in sex and edema (swelling on hands and legs) might be noticed. A person suffering from cirrhosis and damaged liver may notice an increased tendency to bruise and bleed easily. Intense itching is felt on account of the bile products being deposited in the skin. Gallstones may develop as a result of inadequate bile reaching the gallbladder. There might be a buildup of toxins in the brain bringing about bouts of unresponsiveness and forgetfulness. Cirrhosis can bring on Portal hypertension - a condition where there is reduced flow of blood to the portal vein and increased pressure within it. Cirrhosis can eventually lead to liver cancer caused by carcinoma. Impotence, kidney dysfunction and osteoporosis are other likely complications of liver disease.


Cirrhosis of the liver is usually caused by chronic alcoholism or hepatitis C. Other possible factors leading to cirrhosis are problems in the immune system and damaged bile ducts.
Chronic Alcoholism - One of the common causes for cirrhosis is alcoholism. But this condition occurs only after at least 10 years or more of heavy drinking. Alcohol affects the liver's ability to metabolize proteins, fats and carbohydrates.
Chronic hepatitis - Hepatitis C virus can lead to severe inflammation and damage of the liver, thereby causing cirrhosis. Hepatitis B is one of the most common causes of liver inflammation in many of the developing nations.
Blocked bile ducts - In such a condition, the bile is unable to travel out of the liver and instead ends up damaging liver tissue. This can be a congenital defect in some infants.


Cirrhosis of the liver can cause many other abnormalities. It can leads to elevated levels of triglycerides, cholesterol and sugar. Diabetes mellitus is a common fallout. There might be a fall in platelet count and GI bleeding. In severe cases of cirrhosis, there can be an immune system dysfunction or even brain swelling and later coma. The liver of an affected person will feel be larger and harder to touch. A liver scan or ultrasound can help detection of cirrhosis. A liver biopsy is sometimes resorted to. Damage to the liver due to cirrhosis cannot be reversed but further complications can be reduced with the right treatment. Cirrhosis caused by excess alcohol consumption needs lifestyle changes such as avoiding alcohol and following a nutritious diet. Low-sodium diet can help drain excess fluid-buildup within the body. Chronic viral hepatitis B and C are treated with prednisone and azathioprine. Any bacterial infection is treated with appropriate antibiotics. Liver transplantation surgery is done on cases where the liver is not capable of functioning. With the help of modern drugs such as cyclosporine and tacrolimus, the success of liver transplantation surgery has risen manyfold.


Vitamin A

Vitamin A is a fat soluble vitamin which is derived from beta carotene which plays a significant role in the process of vision and other important metabolic pathways pertaining to cell division and genetic expression. The significant forms of vitamin A include retinol, retinal, retinoic acid and retinyl esters. There are approximately six hundred derivatives of beta carotenes and the most important form is retinol.

Functions of Vitamin A

Vitamin A is essential for many metabolic pathways in the body. It is the chief requirement for the function of the rhodopsin protein located in the retina to absorb light and to differentiate functions of the cornea and the conjunctival membranes. Vitamin A is essential for normal functioning of the retina. Apart from this, vitamin A plays a significant role in immune system functions, cell signaling and cellular communication and reproduction. The functions and pathways associated with vitamin A are directly related to the functionality of vital organs such as heart, brain, lungs, liver and kidneys. Hence vitamin A is also known as an important antioxidant. Besides it is required for the growth and differentiation of epithelial tissue, normal growth of bone and embryonic development. Most of our body's Vitamin A is stored in the liver in the form of retinyl esters.


Vitamin A Deficiency: Poor adaptation of vision to darkness or what is known as night blindness is an early symptom that may be followed by degenerative changes in the retina. Degenerative changes in eyes and skin are commonly observed in vitamin A deficiency. The predominant form of vitamin A deficiency is Nyctalopia or night blindness. This occurs as result of retinol imbalance which is the chief derivative of vitamin A. In third-world, vitamin A deficiency is the primary cause of blindness. Pregnant and lactating women, premature children, children living in rural areas of developing countries and patients who have a history of liver diseases such cirrhosis and cystic fibrosis are most susceptible to Vitamin A deficiency. Severe or prolonged deficiency may lead to dry eye or Xerophthalmia (dryness in conjunctiva and cornea of the eye) that can result in corneal ulcers, inflammation, ridge formation, scarring and eventually blindness. Xerophthalmia is due to lacrimal gland dysfunction. Other associated conditions include keratomalacia and follicular hyperkeratosis. Another important consequence of Vitamin A deficiency is acquired immunodeficiency disease, with an increased incidence of death related to infectious diseases. Vitamin A deficiency is associated with increased disease progression and mortality in HIV patients.

World Health Organization (WHO) Recommendations for Vitamin A:
Supplementation may be required in cases where the blood Vitamin A level falls below 20 µg/dL.
Severe deficiency is < 10 µg/dL


Food sources and recommended dietary allowance

Vitamin A is naturally available in dairy products such as milk, cheese, curd, cream. Meat products like liver and fish oil and leafy vegetables are excellent sources of vitamin A. Other sources include pumpkin, potatoes, broccoli, cereals, beans and cow peas. Studies indicate that the intensity of the fruit or vegetable color is directly proportional to the amount of vitamin A present in it. The recommended intake of vitamin A per day for children 500 micrograms, males 1000 micrograms and females 800 micrograms respectively.


RDAs (recommended dietary allowance) for vitamin A are given as mcg of retinol activity equivalents (RAE) to account for the different bioactivities of retinol and provitamin A carotenoids. FDA may introduce new labeling regulations in the near future which may result in listing Vitamin A with RAE values rather than in IU.
The following table shows conversion rates of mcg of RAE (retinol activity equivalents):

  • 1 IU retinol = 0.3 mcg RAE
  • 1 IU beta carotene from dietary supplements = 0.15 mcg RAE
  • 1 IU beta carotene from food = 0.05 mcg RAE
  • 1 IU alpha carotene or beta-cryptoxanthin = 0.025 mcg RAE

Essentially all dietary sources of vitamin A are converted into retinol by the body: 1 mcg of physiologically available retinol is equivalent to the following amounts from dietary sources:

  • 1 mcg of retinol
  • 12 mcg of beta carotene
  • 24 mcg of alpha carotene or beta cryptoxanthin

Hypervitaminosis A: Vitamin A in excess can be toxic. According to WHO, values in excess of 120 µg/dL is Hypervitaminosis A. Chronic vitamin A over dosage may be a serious issue in normal adults who take more than 15 mg per day and in children who take more than 6 mg per day of vitamin A over a period of several months. Symptoms can include :

  • Dry skin
  • Cheilosis
  • Glossitis
  • Hypercalcemia
  • Hyperlipidemia
  • Amenorrhea
  • Liver fibrosis with portal hypertension
  • pseudotumor cerebri
  • increased intracranial pressure and Papilledema
  • lymph node enlargement

Other than that some symptoms such as pain, vomiting, alopecia and bone demineralization may result due to excessive intake of Vitamin A. In pregnant women, an over dose of Vitamin A over a period of time may result in spontaneous abortions or Congenital malformations, craniofacial abnormalities and valvular heart disease in the baby.

However, unlike preformed Vitamin A, beta-carotene is not known to be teratogenic (reproductive toxicity). Even a relatively large supplemental doses of beta carotene or eating carotenoid rich food for long duration need not result in toxicity always. Rarely a reversible condition known as carotenodermia - where the skin turns yellow/orange might be the result of long term over dosage of beta carotene.


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Bibliography / Reference

Collection of Pages - Last revised Date: October 21, 2019