Peritoneal fluid for research is obtained by paracentesis. Paracentesis is performed using a trocar and cannula, which are inserted through the abdominal wall under local anesthesia. If the peritoneal fluid is evacuated for therapeutic purposes, the trocar cannula is attached to the drainage system. However, if only a small amount of peritoneal fluid is needed for examination, both a trocar and an 18-gauge puncture needle can be used. When puncturing all four quadrants of the abdomen, peritoneal fluid is aspirated from each quadrant, which is important for diagnosing damage to the abdominal organs in trauma and timely surgical intervention.

• It should be explained to the patient that the study allows you to clarify the cause of ascites or diagnose damage to the abdominal organs during trauma.
• No restrictions on diet and diet are required.
• The patient should be informed that a sample of peritoneal fluid will be taken during the examination, an abdominal wall puncture will be performed under local anesthesia, which will reduce discomfort, and that the examination will usually take approximately 45 minutes.
• To relieve anxiety in the patient, he should be reassured, assuring that complications in this study are very rare.
• If the patient has ascites, he should be told that the evacuation of ascitic fluid will improve well-being and facilitate breathing.
• It is necessary to ensure that the patient or his relatives give written consent to the study.
• Before the study, the initial basic physiological parameters, body weight are determined and the abdominal circumference is measured.
• The patient should be warned that, if necessary, blood will be taken from him for research.
• Before the study, the patient must urinate, which is important to prevent accidental damage to the bladder by a puncture needle or trocar.
• Before the study, a survey x-ray of the abdomen is also performed.

• The patient is seated on a bed or in a chair so that his feet are comfortably placed on the floor, and his back is securely supported. If it is difficult for the patient to be out of bed, raise the head of the bed high (Fowler high position) and ask the patient to get comfortable.
• The patient is covered to prevent chills, leaving only the puncture site open.
• To prevent bedding from getting wet and the outflow of peritoneal fluid on the patient, a plastic oilcloth is used.
• The hair in the puncture area is shaved off, the skin is treated with a disinfectant solution and covered with sterile diapers.
• The puncture site is anesthetized with a local anesthetic solution.
• The doctor inserts a puncture needle or trocar with a cannula at a level of 2.5-5 cm below the navel, but the puncture of the abdominal wall can also be done in the iliac region, at the edge of the rectus abdominis, in the lateral region, or in each of the four quadrants of the abdomen.
• When using a trocar with a cannula, a small incision is made in the skin to facilitate their introduction through the abdominal wall. The penetration of the needle into the abdominal cavity is accompanied by a characteristic sound. After removing the trocar, the peritoneal fluid is aspirated using a 50 ml syringe. If more peritoneal fluid needs to be evacuated, the syringe is connected with a tubing from an IV line to a plastic bag. You can evacuate no more than 1500 ml of peritoneal fluid. If the fluid is difficult to drain, a trocar with a cannula or a puncture needle should be inserted elsewhere in the abdominal wall.
• After evacuation of the peritoneal fluid, the cannula or needle is removed and the puncture site is pressed down with a sterile napkin, sometimes one suture is applied to the skin wound.
• Peritoneal fluid samples are numbered in the order in which they were obtained. If the patient is receiving antibiotics, this is noted on the laboratory referral form.
• Carefully, in compliance with existing instructions, the used tools are removed, the material for single use is packed in a special container for subsequent destruction.
• A sterile gauze bandage is applied to the puncture site. It must be multi-layered to absorb the outflowing peritoneal fluid. The dressing should be reviewed periodically (for example, at each vital signs test) and changed or secured as necessary.
• It is necessary to periodically determine the main physiological parameters, in the unstable condition of the patient, they are determined every 15 minutes. The patient is weighed and the circumference of the abdomen is measured, after which the results are compared with the original ones.
• The patient is provided with peace and, if possible, refrains from medical and other procedures that may cause him stress (for example, changing bed linen).
• Monitor diuresis for 24 hours, the presence of hematuria indicates damage to the bladder.
• With the evacuation of a significant amount of peritoneal fluid, the risk of collapse increases, so you should be especially careful about symptoms such as pallor of the skin, increased heart rate and respiration, lowering blood pressure and central venous pressure, impaired consciousness, complaints of dizziness. In such cases, if the patient is conscious, he is given fluids to drink.

In connection with the above-mentioned features, by administering intravenous fluids and albumin to patients, the content of electrolytes (especially sodium) and protein in the serum is determined.

Features of the peritoneal fluid are normal.

General Features and Components	Meaning
General signs	Sterile, clear or pale yellow liquid, odorless, in an amount not exceeding 50 ml
red blood cells	Missing
Leukocytes	Less than 300 in 1 µl
Protein	0.3-4.1 g/dl (SI: 3-4.1 g/l)
Glucose	70-100 mg/dl (SI: 3.5-5 mmol/l)
Amylase	138-404 U/l
Ammonia	Less than 50 mg/dL (SI: less than 29 µmol/L)
Alkaline phosphatase	Men over 18: 90-239 U/L Women under 45: 76-196 U/l Women over 45: 87-250 IU/L
Tumor cells (cytological examination)	Missing
bacteria	Missing
Mushrooms	Missing

Turbid peritoneal fluid is observed with peritonitis caused by a primary bacterial infection, intestinal rupture as a result of trauma, pancreatitis, intestinal infarction, strangulation obstruction, appendicitis. Bloody peritoneal fluid is observed in benign and malignant tumors, hemorrhagic pancreatitis, or vessel damage when a trocar is inserted into the abdominal cavity Greenish peritoneal fluid, due to the presence of bile in it, indicates gallbladder rupture, acute pancreatitis, intestinal perforation or duodenal ulcer.

The presence in the peritoneal fluid of more than 100 erythrocytes per 1 μl (SI: 100-106 / l) indicates a tumor or tuberculosis in case of abdominal trauma with damage to internal organs, the number of erythrocytes exceeds 100,000 per 1 μl (SI: 100-109 / l) Increased number leukocytes in the peritoneal fluid, more than 25% of which are neutrophils, is observed in 90% of patients with spontaneous bacterial peritonitis and in 50% of patients with liver cirrhosis. A high content of lymphocytes is characteristic of patients with tuberculous peritonitis or chylous ascites. A large number of mesothelial cells in the peritoneal fluid is also characteristic of tuberculous peritonitis. A protein level of more than 3 g/dl (SI: 30 g/l) is observed in malignant tumors, more than 4 g/dl (SI: 40 g/l) in tuberculosis. Low glucose levels in the peritoneal fluid are observed in patients with tuberculous peritonitis and peritoneal carcinomatosis.

The activity of alkaline phosphatase in the peritoneal fluid increases by more than 2 times compared with the normal activity in the blood serum in patients with intestinal rupture and strangulation small bowel obstruction. A more than twofold increase in the level of ammonia compared to the normal level in the blood serum is observed with intestinal rupture and strangulation of the small intestine or large intestine, with perforated ulcer and perforated appendicitis The ratio of the protein content in the peritoneal fluid to its content in the blood serum, equal to or greater than 0.5 , characteristic of a malignant tumor, tuberculous or pancreatic ascites and indicates an extrahepatic cause of ascites. A ratio less than 0.5 indicates uncomplicated liver cirrhosis. A gradient between the level of albumin in ascitic fluid and serum more than 1 g/dl (SI: more than 10 g/l) indicates chronic hepatitis, a gradient of less than 10 g/l is characteristic of a malignant tumor. A cytological examination of the peritoneal fluid allows us to detect tumor cells, a microbiological examination - E. coli, anaerobes and enterococci that enter the abdominal cavity when a hollow organ ruptures, inflammatory processes of internal organs (appendicitis, pancreatitis), tuberculosis, ovarian diseases. Identification of gram-positive cocci usually indicates primary peritonitis. With histoplasmosis, candidiasis or coccidioidomycosis, fungi are found in the peritoneal fluid.

The accumulation of free fluid in the abdominal cavity occurs as a result of an inflammatory reaction, a violation of the outflow of lymph and blood circulation due to various reasons. A similar condition is called ascites (dropsy), its appearance can lead to the development of serious consequences for human health.

The fluid accumulated in the peritoneum is an ideal habitat for pathogenic microflora, which is the causative agent of peritonitis, hepatorenal syndrome, umbilical hernia, hepatic encephalopathy and other equally dangerous pathologies.

To diagnose ascites, one of the safest and most non-invasive, but highly accurate methods is used - a study using ultrasound waves. Detection of the presence of fluid in the abdominal cavity by ultrasound is carried out as prescribed by the attending physician on the basis of existing clinical signs of the pathological process.

The abdominal cavity is a separate anatomical zone, which constantly releases moisture to improve the sliding of the visceral sheets of the peritoneum. Normally, this effusion is able to be dynamically absorbed and not accumulate in areas convenient for it. In our article, we want to provide information about the causes of abnormal fluid reserve, the diagnosis of a pathological condition on ultrasound, and effective methods for its treatment.

Why does free fluid accumulate in the abdominal cavity?

Ascites develops as a result of various kinds of pathological processes in the pelvic organs. The initially accumulated transudate is not inflammatory in nature, its amount can range from 30 ml to 10-12 liters. The most common causes of its development are a violation of the secretion of proteins that provide impermeability to tissues and pathways that conduct lymph and circulating blood.

This condition can be provoked by congenital anomalies or development in the body:

• cirrhosis of the liver;
• chronic heart or kidney failure;
• portal hypertension;
• protein starvation;
• lymphostasis;
• tuberculous or malignant lesions of the peritoneum;
• diabetes;
• systemic lupus erythematosus.

Often, dropsy develops during the formation of tumor-like formations in the mammary glands, ovaries, digestive organs, serous membranes of the pleura and peritoneum. In addition, free fluid can accumulate against the background of complications of the postoperative period, pseudomyxoma of the peritoneum (an accumulation of mucus that undergoes reorganization over time), amyloid dystrophy (disturbances in protein metabolism), and hypothyroid coma (myxedema).

The mechanism for the formation of dropsy is leakage into the abdominal cavity of fluid from the main lymphatic ducts, blood vessels and organ tissues.

Signs of ascites

In the early stages of the development of this condition, patients do not have any complaints, the accumulation of free fluid can only be detected using ultrasound. Visible symptoms appear when the amount of transudate exceeds one and a half liters, a person feels:

• an increase in the abdominal part of the abdomen and body weight;
• deterioration in general well-being;
• feeling of fullness in the abdominal cavity;
• swelling of the lower extremities and scrotum tissues (in men);
• belching
• heartburn;
• nausea;
• difficulty breathing;
• flatulence;
• tachycardia;
• protrusion of the umbilical node;
• discomfort and pain in the abdomen;
• stool and urinary disorders.

When a large amount of effusion accumulates in the peritoneum, a person can hear a characteristic splash of fluid and feel a wave.

If an ultrasound examination of the abdominal cavity showed the presence of excess moisture, the attending physician needs to accurately establish the root cause of the pathological condition. Pumping out accumulated transudate is not an effective treatment for ascites.

Preparation for ultrasound and its course

This study does not have any contraindications or restrictions; in emergency cases, it is carried out without prior preparation of the patient. A planned procedure requires improved visualization of pathological changes in organs. The patient is recommended to exclude foods containing a large amount of fiber and increasing gas formation from the diet 3 days before the study.

On the eve of the study, drink a laxative or make a cleansing enema. To reduce the accumulation of gases in the intestines on the day of the ultrasound, you need to take Mezim or activated charcoal. Modern methods of ultrasound diagnostics make it possible to determine the most probable areas of accumulation of free fluid in the abdominal cavity.

That is why qualified specialists examine the following anatomical zones:

• The upper "floor" of the peritoneum, which is located under the diaphragm. Of particular diagnostic importance are the spaces located under the liver and formed by the main section of the small intestine - the ascending and descending parts of the colon. Normally, the so-called lateral channels do not exist - the covers of the peritoneum fit snugly against the intestine.
• The small pelvis, in which, with the development of pathological processes, effusion can accumulate, flowing from the lateral canals.

The physical features of the moisture accumulated in the peritoneum for any reason do not allow the ultrasonic wave to be reflected, this phenomenon makes the diagnostic procedure as informative as possible. The presence of effusion in the studied anatomical spaces creates a dark moving focus on the monitor of the apparatus. In the absence of free fluid, diagnostics last no more than 5 minutes.

To detect excess moisture, the probe of the ultrasound device is moved along the anterior and middle axillary lines on both sides of the patient's body from top to bottom of the abdomen.

If it is not possible to detect a transudate, indirect signs may indicate its presence:

• displacement of the colon loops;
• change in sound during percussion (tapping) - tympanic in the upper parts of the peritoneum, blunt in the lower.

Types of abdominal dropsy on ultrasound

The international classification of diseases does not single out ascites as a separate disease - this condition is a complication of the last stages of other pathological processes. According to the brightness of clinical symptoms, the following forms of ascites are distinguished:

• initial - the amount of water accumulated inside the abdomen reaches 1.5 liters;
• with a moderate amount of liquid- manifested by swelling of the legs, a noticeable increase in the size of the chest, shortness of breath, heartburn, constipation, a feeling of heaviness in the abdomen;
• massive (the volume of effusion is more than five liters) - a dangerous condition characterized by tension in the walls of the abdominal cavity, the development of insufficiency in the function of the cardiac and respiratory systems, and infection of the transudate.

In the bacteriological assessment of the quality of the free fluid, which is produced under special laboratory conditions, a distinction is made between sterile (absence of pathogenic microorganisms) and infected (presence of pathogenic microbes) dropsy.

According to diagnostic forecasts, there is ascites, which is amenable to drug therapy, and a stable pathological condition (its recurrence or not amenable to treatment).

What is done after confirmation of the pathology by ultrasound?

The course of therapeutic measures depends on what disease caused the accumulation of excess moisture in the peritoneum. To accurately diagnose the pathological process, practitioners conduct a comprehensive examination of the patient, including:

• biochemical and general clinical blood and urine tests;
• study of oncological markers and indicators of electrolyte metabolism;
• survey radiography of the chest and abdominal cavities;
• coagulogram - evaluation of the parameters of the coagulation system;
• angiography of blood vessels, which allows to assess their condition;
• MRI or CT scan of the abdomen;
• hepatoscintigraphy - a modern technique for examining the liver using a gamma camera, which allows visualizing the organ;
• diagnostic laparoscopy with therapeutic puncture of ascitic fluid.

To pump out the transudate from the abdominal cavity, the method of therapeutic laparocentesis is used - a puncture is made in the anterior wall of the abdomen, through which excess fluid is removed

In patients with cirrhosis of the liver, an intrahepatic portosystemic shunt is recommended, the technique of which is to place a metal mesh stent, to create an artificial connection between the collar and hepatic veins. In severe cases, an organ transplant is necessary.

In conclusion of the above information, I would like to emphasize once again that the accumulation of free fluid in the abdominal cavity is considered an unfavorable manifestation of the complicated course of the underlying disease. The development of ascites can provoke a violation of the functional activity of the heart and spleen, internal bleeding, peritonitis, cerebral edema.

The mortality rate of patients with a massive form of abdominal dropsy reaches 50%. Measures that prevent the occurrence of this pathological condition are the timely treatment of infectious and inflammatory processes, proper nutrition, refusal to drink alcohol, moderate exercise, preventive examinations of medical specialists and the exact implementation of their recommendations.

Peritoneal dialysis is a method of artificial purification of blood from toxins, based on the filtration properties of the patient's peritoneum.

The peritoneum is a thin membrane that completely or partially covers the internal organs of the abdominal cavity. In physical terms, the peritoneum is a membrane with selective permeability for various substances. The peritoneum has three types of pores: small, water-permeable, medium, for the passage of water-soluble compounds and substances with a small molecular weight, and large - for substances with a large molecular weight. Due to its large penetrating ability, the peritoneum is able to pass various types of toxins. This distinguishes the method of peritoneal dialysis from hemodialysis, in which only substances with a small and partially medium molecular weight pass through the membrane.

In peritoneal dialysis, the dialysis solution (dialysate) is located in the abdominal cavity and constantly filters toxins from the vessels in the peritoneal wall. Within a few hours, the dialysate becomes contaminated with toxins, the filtration process stops, which requires the replacement of the solution.

The speed and volume of filtration is constant, the cleaning process is slow and long, which allows the use of peritoneal dialysis in patients with low or unstable blood pressure and in children. In addition to filtration during peritoneal dialysis, excess fluid enters the solution. This process is called ultrafiltration. The dialysate contains an osmotic active substance, such as a concentrated glucose solution, which attracts liquid along the concentration gradient. As a result, excess fluid from the bloodstream through the vessels of the peritoneum enters the dialysis solution. In addition to glucose, amino acids, dextrose, glycerol, starch are present as an osmotic agent in some dialysis solutions. In addition, the dialysate contains a complex of chemicals, selected depending on the needs of the patient.

Indications for peritoneal dialysis

Peritoneal dialysis is preferable to hemodialysis in the following cases:

For patients in whom it is not possible to create adequate vascular access (persons with low blood pressure, severe diabetic angiopathy, young children).

For patients with severe diseases of the cardiovascular system, in whom hemodialysis sessions can lead to the development of complications.

For patients with bleeding disorders, in whom the use of drugs that prevent thrombosis is contraindicated.

For patients with intolerance to synthetic hemodialysis filter membranes.

For patients who do not want to depend on a hemodialysis machine.

Contraindications for peritoneal dialysis

Peritoneal dialysis is contraindicated in:

The presence of adhesions in the abdominal cavity, as well as an increase in internal organs, which limits the surface of the peritoneum.

With established low filtration characteristics of the peritoneum.

The presence of drainage in the abdominal cavity in adjacent organs (colostomy, cystostomy).

Purulent diseases of the skin in the abdominal wall.

Mental illness, when the patient is not able to properly conduct a session of peritoneal dialysis.

Obesity, when the effectiveness of blood purification in peritoneal dialysis is questioned.

peritoneal dialysis procedure

The kit for peritoneal dialysis includes containers (empty and with solution) and conductive lines.

Cyclers are also used during the procedure. The cycler is a device that provides programmable cycles for filling and draining the solution, as well as being able to heat the solution to the desired temperature and weigh the drained dialysate to estimate the volume of fluid removed.

Peritoneal catheters are used to access the abdominal cavity.

Catheters should provide good drainage of the abdominal cavity, be tightly fixed, and be protected from infection. Adequate irrigation of the abdominal cavity is carried out due to the high speed of filling and draining the solution. The catheter is tightly fixed in the subcutaneous fat due to the germination of the Dacron cuff with connective tissue. It also creates a barrier to infection. Catheters are made of silicone or polyurethane. The catheter is placed surgically into the pelvic cavity. The outer part of the catheter is brought out under the skin on the anterior or lateral surface of the abdominal cavity.

After placing the catheter for adequate fixation, 2-3 weeks should pass, after which they begin to conduct dialysis sessions.

For peritoneal dialysis, it is necessary to attach a container filled with dialysis solution to the catheter.

This process takes place subject to hygienic and antiseptic rules, including the treatment of hands, work surfaces, the skin around the catheter, as well as the junctions of the lines and the catheter (adapter), putting on a mask on the face. The front surface of the abdomen is freed from clothing, a clean cotton towel is tied to the belt. From the sterile bag, a drain empty bag and a container with fresh dialysis solution are taken out. In this case, the container with fresh solution is hung on a tripod at a height of 1.5 m, and the drain bag is placed on the floor. The mains after treatment with an antiseptic solution are interconnected.

First, the solution is drained into an empty bag. Then this part of the highway is pinched, the clamp opens on the bringing branch of the highway. New dialysis fluid is poured into the abdominal cavity. After that, the clamps on the lines are clamped, the empty container and the bag with the drained solution are removed. The outer port of the catheter is closed with a protective cap, fixed to the skin and hidden under clothing. Every month, patients take blood and fluid from the abdominal cavity for examination. Based on the results, a conclusion is made about the degree of blood purification, as well as the presence or absence of anemia, disorders of phosphorus-calcium metabolism, and, based on these indicators, the treatment is corrected. On average, exchange sessions are carried out 3 times a day, the volume of dialysis solution is 2-2.5 liters.

In case of poor tolerance, non-compliance with the regimen, insufficient blood purification, as well as in the event of severe or recurring complications, it is recommended to transfer the patient to hemodialysis.

Complications of peritoneal dialysis

The most dangerous complication of peritoneal dialysis is peritonitis (inflammation of the peritoneum). The most common reason for the development of inflammation is the patient's failure to follow the rules of antiseptics during exchange sessions. Peritonitis is diagnosed when two of three signs are present:

External manifestations of inflammation of the peritoneum: pain in the abdomen, fever, chills, general weakness, nausea, vomiting, impaired stool.

Turbid peritoneal fluid.

Detection of bacteria in peritoneal fluid.

Treatment: broad-spectrum antibiotics until the test results, then an antibacterial drug, taking into account the sensitivity of the identified microorganisms to it. In addition to specific therapy, a temporary cessation of peritoneal dialysis sessions, washing of the abdominal cavity with a standard dialysis solution or Ringer's lactate solution is recommended. Heparin is added to the solutions during washing, which prevents the adhesive process in the abdominal cavity. In severe cases, removal of the peritoneal catheter may be necessary.

Non-infectious complications include the following:

Violation of the abdominal catheter with difficulty filling / draining the solution. This complication may be due to a change in the location of the catheter, closure of the catheter by a loop of intestine, for example, with constipation, bending of the catheter, or closure of the lumen of the catheter with blood clots or fibrin, which is often found in peritonitis. When closing the lumen of the catheter with clots, you can try to flush it with a sterile isotonic solution. If unsuccessful, catheter replacement is indicated. Complications associated with changing the position of the catheter require surgical intervention.

When the gulf is found and the dialysis solution is in the abdominal cavity, intra-abdominal pressure increases, which contributes to the formation of hernias. The most common hernias of the white line, less often umbilical and inguinal hernias. Depending on the size and reducibility of the hernial protrusion, the question of further treatment is decided: surgery or expectant management.

The outflow of peritoneal solution outward or into the subcutaneous fatty tissue occurs, as a rule, immediately after the placement of an intra-abdominal catheter, or with poor fixation of the catheter in elderly and debilitated patients. This complication is diagnosed when the bandage gets wet in the area of ​​the catheter, or when edema of the subcutaneous fat of the abdominal wall and genitals forms. Treatment consists in stopping peritoneal dialysis for 1-2 weeks for optimal fixation of the catheter, with the patient undergoing hemodialysis sessions. Under adverse conditions, catheter replacement is indicated.

Right-sided pleurisy occurs in debilitated patients, as well as in some patients at the beginning of treatment. This complication is associated with the penetration of dialysis fluid through the diaphragm into the pleural cavity. Treatment - reducing the volume of the poured solution. To prevent this condition, it is recommended to conduct exchange sessions in a vertical state. With an increase in respiratory failure, the transfer of the patient to program hemodialysis is indicated.

Abdominal pain that is not associated with inflammation of the peritoneum often occurs at the beginning of treatment and disappears after a couple of months. The pain is usually associated with irritation of the peritoneum by a chemically active dialysis solution, or due to overdistension of the abdominal cavity with a large amount of solution. In the first case, the treatment consists in the selection of the dialysate that is optimal in chemical composition, in the second case, the filling of smaller volumes of solutions with an increase in the frequency of exchanges.

Many experts consider peritoneal dialysis as the first stage of replacement therapy for patients in the terminal stage of renal failure. In some patients, for a number of reasons, peritoneal dialysis is the only possible treatment.

Compared with hemodialysis, peritoneal dialysis allows patients to lead an active lifestyle and work. But, unfortunately, the duration of treatment with peritoneal dialysis directly depends on the filtering properties of the peritoneum, which, over time, gradually, and with frequent peritonitis rather quickly, decrease. In this case, there is a need for alternative methods: hemodialysis or kidney transplantation.

Therapist, nephrologist Sirotkina E.V.

peritoneal fluid is a lubricating fluid (produced and absorbed by the peritoneum) found in the abdominal cavity. The abdomen is the space between the abdominal organs (such as the stomach, spleen, liver, and gallbladder) and the membrane that lines the abdominal wall.

Peritoneal fluid is a clear, sterile fluid composed primarily of water and small amounts of white blood cells, antibodies, electrolytes, and other biochemicals. The main function of peritoneal fluid is to reduce friction caused by the movement of the abdominal organs.

Reasons for analysis

In healthy people, the abdominal cavity contains a small amount of peritoneal fluid. But certain problems can lead to its excessive accumulation. This fluid, also called ascitic fluid, can lead to a condition called ascites. This is one of the complications caused by cirrhosis.

Some infections and microorganisms can also cause peritonitis, an inflammation of the peritoneal membrane.

In this case, culture of peritoneal fluid is performed. It is needed in order to diagnose the problem and begin treatment.

Culture of peritoneal fluid

This is a laboratory test in which a sample of fluid is taken from the abdominal cavity, which is then examined for microorganisms, bacteria and fungi that can cause infection.

Procedure

Some peritoneal fluid will be removed from the abdomen and sent to the laboratory for culture and gram staining. The sampling procedure is called .

Training

Before starting a laparocentesis, it is necessary to empty the bladder.

The puncture site will be cleaned with an antiseptic.

Anesthetize (using local anesthesia).

They will insert a needle (or a trakar with a canula, for which they may make a small incision) and remove a sample of fluid.

When extracting a large volume of fluid, the patient may feel slightly dizzy.

Risks associated with the procedure

There is a small risk that the needle will pierce the bladder, intestines, or blood vessel. This can lead to perforation and bleeding or infection of the intestine.

Ovarian and cervical cancer are the leading cancers leading to death in women. The insidiousness of these diseases is that they often do not manifest themselves in any way or have mild symptoms. Because of this, the tumor can grow to a serious size before it is detected. Cytological examination of the peritoneal fluid can be very helpful in detecting cancer cells or other genetic abnormalities of the ovaries and cervix at an early stage.

The Douglas space, or retrouterine space, is an anatomical space located in the back of the woman's small pelvis. It is located between the posterior wall of the uterus, the cervix, the vaginal posterior fornix and the anterior wall of the rectum. In physiological terms, the space of Douglas is said to be free, that is, it does not contain fluid or tissue.

The presence of traces of fluid in the retrouterine space may indicate ovulation, in which case there is no cause for concern. A larger volume of fluid can be visualized during transvaginal ultrasound. It is always necessary to determine the nature of the detected secret - bloody fluid, peritoneal fluid (ascites), pus, etc. For this purpose, a diagnostic puncture of the retrouterine space is often performed to obtain material for research and determine the probable cause of fluid accumulation.

The causes of the presence of fluid in the Douglas space, as a rule, are diseases of the genital organs, but not always. If fluid in the retrouterine space appears on certain days of the menstrual cycle, there is no cause for concern.

Sexually mature women and girls regularly - especially immediately after ovulation (just after half a cycle) - have a small amount of free fluid. However, if the presence of fluid is detected in the first phase of the cycle or at the end of the second, and in large quantities, then pathology of the uterine appendages or abdominal cavity can be suspected.

Fluid in the retrouterine space causes

The most common causes of fluid behind the uterus are diseases:

• rupture of an ovarian cyst;
• dropsy of the ovary;
• endometriosis;
• rupture of an ectopic pregnancy;
• adnexitis;
• ovarian cancer;
• peritonitis;
• enteritis;
• cirrhosis of the liver;
• ovarian hyperstimulation (after hormonal stimulation).

Depending on the nature of the fluid behind the uterus:

The presence of bloody fluid behind the uterus can result from:

• bleeding into the abdominal cavity from the pelvic organs,
• rupture of an ectopic pregnancy,
• ruptured ovarian cysts
• foci of peritoneal endometriosis.

A large amount of ascitic (peritoneal) fluid may be due to:

• female genital cancer (cancer of the ovary, fallopian tube, cervix),
• cirrhosis of the liver,
• circulatory failure.

The presence of purulent fluid may indicate:

• inflammation of the small pelvis (for example, appendages);
• or abdominal cavity (eg, peritonitis, inflammatory bowel disease).

Diseases in which there is free fluid in the space of Douglas

Rupture of an ovarian cyst

An ovarian cyst is an abnormal space inside the ovary surrounded by a wall. There are several types of ovarian cysts: simple, serous fluid-filled, dermoid cysts, and endometrial cysts (chocolate cysts that form during endometriosis). Sometimes a cyst can form at the site of an unruptured follicle around the time of ovulation - this type of cyst tends to spontaneously reabsorb. Unfortunately, it can also happen that a cyst in the ovary indicates the presence of cancer. Cysts may sometimes cause no symptoms and are discovered incidentally during a routine abdominal ultrasound. Sometimes, however, their presence can cause various ailments:

• menstrual irregularities,
• irregular bleeding not related to the menstrual cycle,
• abdominal pain,
• pain in the area of ​​the ovary where the cyst is located.

It happens that the cyst ruptures, then the woman feels severe pain, and during the abdominal ultrasound they find the presence of fluid in the retrouterine space. Treatment of cysts, if they do not give any symptoms, can only consist in their systematic observation. However, if cysts cause problems or enlarge, they need to be removed (either laparoscopically or conventionally, depending on the type of cyst).

Rupture of an ectopic (ectopic) pregnancy

When does an ectopic pregnancy occur? An ectopic pregnancy occurs when fertilized eggs implant in a different location than the body of the uterus. The frequency of ectopic pregnancy is estimated at about 1% of all pregnancies. The most common site of an ectopic pregnancy is the fallopian tube. In fact, the embryo can implant almost anywhere: in the cervix, ovary or abdomen. The most dangerous for the health and life of a woman is an abdominal or cervical pregnancy, but, fortunately, they occur very rarely.

What are the symptoms of an ectopic pregnancy? During an ectopic pregnancy, abnormal discharge and bleeding may occur, in addition, there are abdominal pains, sometimes difficulty with defecation. In a situation where an ectopic pregnancy ruptures, there is sharp pain in the abdomen, while an ultrasound will reveal fluid in the pouch of Douglas. The treatment of an ectopic pregnancy is always surgical.

Inflammation of the appendages

For adnexitis, the so-called ascending path is characteristic - vaginal microbes enter the higher organs of the female reproductive system. Until recently, the most common pathogen causing inflammation of the appendages was gonococcus. Currently, due to a significant decrease in the incidence of gonorrhea, the bacterium is no longer the most common organism. The following pathogens are also included in the etiological factors of adnexitis:

• chlamydia;
• mycoplasma genitalis and other mycoplasmas;
• coli;
• group B streptococci and other streptococci;
• Gardnerella gardnerella vaginalis.

Chlamydia and gonococci have the largest share in the formation of infection leading to inflammation of the appendages.

What are the symptoms of adnexitis? First of all, there may be pain in the lower abdomen, usually the pain is bilateral. In addition, dyspareunia (pain during intercourse) may be present, as well as abnormal discharge from the genital tract associated with inflammation of the cervix or vagina. There is abnormal bleeding - intermenstrual bleeding or very heavy menstrual bleeding and fever above 38 C. Ultrasound examination may reveal the presence of fluid behind the uterus. Treatment of inflammation of the appendages is the use of antibiotics and symptomatic therapy.

ovarian cancer

This cancer does not cause any symptoms for a long time, the presence of symptoms such as pain in the lower abdomen, enlargement of the abdominal cavity or vaginal bleeding, unfortunately, indicates the severity of the cancer.

Peritonitis

The presence of purulent fluid in the retrouterine space may indicate the presence of peritonitis and requires clarification of the diagnosis and examination of the gastrointestinal tract and urinary tract.

Symptoms of Fluid in Douglas Space

Symptoms depend on the cause of fluid accumulation. For example, in the event of a rupture of an ovarian cyst, pain in the abdominal cavity may appear, which periodically become sharp and cutting, nausea and vomiting, diarrhea, and loss of appetite. When an ectopic pregnancy ruptures, spotting and bleeding from the vagina, pain in the lower abdomen, pain in the ovaries, and sometimes a feeling of incomplete emptying of the intestine.

With inflammation of the appendages, there is a sudden cramping pain on both sides of the abdomen, aggravated during intercourse. Sometimes it radiates to the groin and thighs. Accompanied by weakness, fever or febrile state.

Diagnostic puncture through the posterior fornix of the vagina

Puncture of the retrouterine space is a simple invasive method, especially useful for diagnosing bleeding in the abdominal cavity of the pelvic organs and for detecting a disturbed ectopic pregnancy. The procedure is performed under general anesthesia in a hospital setting. The puncture of the Douglas pocket is performed through the vagina using a 20 ml syringe and a needle with a length of min. 20 cm and 1.5 mm in diameter. After inserting a speculum, the gynecologist inserts a needle through the posterior fornix of the vagina, and then aspirates its contents into a syringe.

Sometimes the puncture is performed under ultrasound guidance to avoid the risk of puncturing large pelvic vessels. After the needle is removed, the contents of the syringe are carefully examined. The obtained material can also be transferred for cytological or bacteriological examination. Detection of fragments of clots or bloody fluid may indicate bleeding into the abdominal cavity due to a disturbed ectopic pregnancy. This condition, with the presence of clinical, laboratory and ultrasound symptoms, is an indication for surgery to remove a disturbed ectopic pregnancy, most often using the laparoscopic method.

The lack of content obtained by puncture of the retrouterine cavity does not exclude bleeding into the peritoneal cavity or the existence of an ectopic pregnancy, especially when symptoms indicate peritoneal irritation. Bleeding may be minimal or there may be post-inflammatory adhesions that prevent collection of material for examination. The presence of bloody fluid can also indicate endometriosis. The bloody contents of the Douglas cavity can become infected (superinfection), worsening the condition of a patient with endometriosis. Treatment includes aspiration of hemolyzed blood from the pouch of Douglas and laparoscopic removal of the endometriosis.

Cytological examination of the fluid

The detection of an increased amount of peritoneal fluid may be sufficient reason for maintaining oncological activity. Ascitic fluid collected at the time of puncture of the retrouterine cavity should be sent for cytological examination to confirm or exclude a tumor. Detection of the presence of cancer cells in the fluid from the abdominal cavity provides valuable information for the doctor, as it may indicate the appearance of a primary malignant neoplasm of the female genital organs.

In women who have previously had cancer and have undergone surgery, this symptom may indicate a recurrence of the cancer. As a rule, the presence of tumor cells in the peritoneal fluid is associated with a high prevalence of female genital cancer, which is an unfavorable prognostic factor in these patients. It should be noted that cytological examination of fluid from the peritoneal cavity is only an auxiliary method in detecting malignant tumors of the ovary, fallopian tube, and cervix.

Cytological examination of the fluid sediment can also reveal an increased number of inflammatory cells that appear with various inflammations of the pelvic organs. Finally, an increased amount of peritoneal fluid is the result of other diseases, such as cirrhosis of the liver or circulatory failure.

When should you see a doctor?

Patients should seek immediate medical attention if, in addition to increased fluid in Douglas's cavity, the following symptoms are present:

• abdominal pain,
• painful intercourse,
• bleeding from the genital tract, not associated with menstruation, contact bleeding,
• nausea, vomiting,
• a rapid increase in the circumference of the abdominal cavity,
• fever, chills,
• weight loss.

Treatment

Treatment depends on the cause of fluid in the retrouterine space. For example, if an ovarian cyst ruptures, surgery is usually needed to remove the cyst. If an ectopic pregnancy ruptures, it must be removed laparoscopically.