Aim: To determine the frequency, the clinical and etiological aspects of ascites in the Internal Medicine Division of the University Hospital of Porto-Novo. Methods: It was a cross-sectional study with a descriptive focus covering the period from January 16 to August 31, 2015. It covered patients hospitalized for ascites in Internal Medicine Department at the Departmental University Hospital of Porto-Novo during the study period. Data were collected on a survey sheet and entered by Excel and analyzed with SPSS. The Chisquare test was used for statistical analysis and a significance threshold of 5% was retained. Results: Of the 511 hospitalized patients during the study period, 61 (11.9%) had ascites. The mean age was 49.6 ± 13.6 years with extremes of 19 years and 80 years. There was a male predominance with a sex ratio of 2.05. Ascites were often type III (34 patients, 55.7%), or type II (22 patients, 36.1%). The frequent signs were hepatomegaly (65.6%), splenomegaly (45.9%), pelvic limb edema (44.3%), and abdominal collateral venous circulation (39.3%). The macroscopic appearance of the ascites fluid was dominated by citrin yellow (82%), followed by hazy (11.5%). The hematic appearance was found in 6.5% of the cases. Hepatic cirrhosis was the most frequent etiology (34.4%) followed by overall heart failure (21.0%). Hepatocellular carcinoma was found in 16% of cases and nephrotic syndrome in 10% of cases. Conclusion: The etiological diversity of ascites, found in our study, imposes a careful clinical and paraclinical approach.
Ascites is a fluid extravasation in the peritoneal cavity. Its etiological diagnosis requires careful clinical examination and a cautious choice of complementary examinations. Generally, ascites is a very common manifestation of decompen- sation of hepatic cirrhosis [
In Sub Saharian Africa, cirrhosis is a less frequent cause of ascites, as shown by a study in Mali in which it counted for 23.3% of cases of ascites [
The study was transversal with a descriptive purpose and carried out from January 16 to August 31, 2015. The study was carried out on all hospitalized patients with ascites admitted in Internal Medicine Department at the Departmental University Hospital of Porto-Novo during the period. Were included, all patients with clinically-proved or discovered abdomino-pelvic ultrasound and confirmed during a puncture. Patients with haemoperitoneum or pyoperitoneum were not included. We conducted a systematic, non-probabilistic recruitment of all hospitalized patients with ascites in the department. Ascites was a dependent variable. Independent variables were: demographics, history, clinical and paraclinic characteristics, and etiologies. All patients included underwent an extensive physical examination and had a paraclinical assessment according to the etiological orientation of each case. No liver biopsy or laparoscopy was performed. The patients were informed about the nature of the study and the impact the results could have on their care. The fact sheets were completed in anonymity by means of an identification number guarantying the confidentiality of the data.
Data were recorded on a survey sheet and entered in Excel and analyzed with SPSS. Data processing was made with Microsoft Word 2010. The chi-square test was used for statistical analysis. The level of statistical significance retained was 5%.
A total of 511 patients were hospitalized in Internal Medicine of the Departmen- tal University Hospital of Porto-Novo. Of these patients, 61 had ascites and were booked as a sample of our study, which is a hospital prevalence of 11.9%.
The mean age was 49.6 years 13.6 with extremes 19 years and 80 years.
The sex ratio was 2.05 with a male representing 67.2% of the cases.
Patients mostly lived in urban areas 33 (54.1%) with 28 (45.9%) in rural areas. At the professional level, traders (24.6%) and craftsmen (18.0%) were the most represented.
Most patients in our sample had type III ascites (34 patients, 55.7%), followed by those with type II ascites (22, 36.1%). Type I was present in only 8% of patients.
Forty (40) patients (65.6%) had hepatomegaly, 28 (45.9%) had splenomegaly and 27 (44.3%) had pelvic limb edema. Collateral venous circulation was associated with ascites in 39.3% (
The macroscopic appearance of the ascites fluid was dominated by citrin yellow (82%), followed by hazy (11.5%). The hematic appearance was found in 6.5% of the cases.
Hepatic cirrhosis was more prevalent in patients (34.4%) followed by overall heart failure (21.0%). Hepatocellular carcinoma was found in 16% of cases and nephrotic syndrome in 10% of cases (
Variables | Population n = 61 |
---|---|
Median age | 49.6 (19 - 80) |
Sex (M/F)% | 67.2/32.8 |
Geographical zone (%) | |
Urban | 33 (54.1) |
Rural | 28 (45.9) |
Alcoholism (%) | 25 (41.0) |
Hypertension (%) | 18 (29.5) |
Smoking (%) | 18 (29.5) |
Diabetes (%) | 4 (6.6) |
History of jaundice (%) | 3 (4.9) |
Signs | Number | Frequency |
---|---|---|
Hepatomegaly | 40 | 65.6 |
Splenomegaly | 28 | 45.9 |
FE | 27 | 44.3 |
C.V.C | 24 | 39.3 |
Jaundice | 17 | 27.9 |
HT | 16 | 26.2 |
Tachycardia | 12 | 19.7 |
Turgescence of the jugular | 10 | 16.4 |
Hyperthermia | 8 | 13.1 |
Facial puffiness | 4 | 6.6 |
Abdominal mass | 1 | 1.6 |
Digestive haemorrhages | 1 | 1.6 |
FE: Feet Edema; CVC: Collateral Venous Circulation; HT: Hypertension.
The substantial preponderance of our cirrhotic patients were male (85.7%). This male majority was also found in hepatocellular carcinoma and heart failure. But the sex ratio was equal to 1 in other etiologies. The hematic appearance of the ascites fluid was found only in peritoneal tuberculosis and cancers (
Diagnostic | Macroscopic aspect of ascites fluid | ||
---|---|---|---|
Citrin yellow | Hazy | Hematic | |
Bacterial ascites | 0 | 1 | 0 |
Peritoneal tuberculosis | 0 | 2 | 2 |
Hepatocellular carcinoma | 8 | 1 | 1 |
Cirrhosis | 21 | 0 | 0 |
Heart failure | 12 | 1 | 0 |
Kidney failure | 2 | 0 | 0 |
Syndrome of demons meig | 0 | 1 | 0 |
Nephrotic syndrome | 6 | 0 | 0 |
Unknown | 1 | 1 | 1 |
Total | 50 | 2 | 4 |
Cirrhosis | HCC | HF | TB | Nephropathies | Unknown |
---|---|---|---|---|---|
Mean age 40 | 60 | 40 | 50 | 40 | 50 |
Sex | |||||
Male 85.7% | 60% | 69.2% | 50% | 50% | 50% |
Female 14.3% | 40% | 30.8% | 50% | 50% | 50% |
Motive for consultation | |||||
abdominal mass+ | + | + | + | ||
Abdominal mass-OMI | + | ||||
Dyspnoea | + | ||||
Abundance of ascites | |||||
Type I | + | + | |||
Type II+ | + | + | + | ++ | + |
Type III++ | + | ||||
Ascites fluid aspect | |||||
Citrin yellow 100% | 80% | 92.3% | 100% | 25% | |
Unclear | 10% | 7.7% | 50% | 50% | |
Hematic | 10% | 50% | 25% | ||
Proteins rate | |||||
Higher to 30 g | + | + | + | ||
Lower to 30 g+ | + | + | + |
HCC: Hepatocellular Carcinoma; HF: Heart Failure; TB: Tuberculosis; FE: Feet Edema.
This transversal and descriptive study made it possible to note a hospital preva- lence of 11.94% for ascites. Our incidence is superimposable to that of Bambara [
In the present study, a male predominance was noted with a sex ratio of 2.05. This male predominance could be explained by the overexposure of men to etiological factors of cirrhosis (alcoholism, hepatitis B) which is the main cause of ascites in our series. To this could be added the relative protection of women during periods of genital activity against hepatic fibrosis: hormones play a preponderant role here. This male predominance is found in the majority of studies but in variable proportions: Drabo et al. [
On the other hand, the study by Sidibé [
The trend in the sex ratio of liver diseases is expected to reverse: Hepatitis B will tend to decline due to a widespread vaccination; those associated with metabolic syndrome (steatohepatitis) will tend to increase. The most affected age group in our study population is adults aged from 30 to 60 years. This age group, which represents the productive force, particularly in the developing countries, counts for 68.3% of the patients in the sample.
The most affected age groups according to Sidibé [
The relatively young age of our patients could be explained by the etiology of ascites: in our context, the etiology of ascites is dominated by hepatopathies among which viral hepatitis (HBV) is a risk factor. Nevertheless, its transmission is mother to child related, especially horizontal during early childhood and remains long in the subclinical stage [
The other patterns were dyspnea (13.11%), edema (8.2%) and abdominal mass (3.3%).
34 patients (55.7%) had type III ascites followed by type II ascites (22 patients, 36.1%). These results are consistent with the data of African series in relation with the delay of patients’ consultation. Dembélé et al. [
In fact, abdominal distension is considered in our communities as a water- filled earthenware jar mystically introduced into the abdomen [
Cirrhosis was the most frequent etiology in our study with a rate of 34.4% or one case in three, associated with a male predominance. This frequency was similar to that found by Dembélé [
Although higher, our results were lower than those of Ouattara et al. [
In France, the presence of ascites is linked to a hepatopathy, mainly cirrhotic, in 80% of cases, mainly of alcoholic origin [
It is rather close to that reported by Ouattara et al. [
In our study, a malignant transformation of cirrhosis was noted in several patients. Alpha Foeto Protein levels were elevated in 16.4% of patients. In these cases, an ultrasound has individualized hepatic nodules greater than 2 cm. Men over 60 were frequently affected. This result is consistent with the literature’s finding that CHC occurs frequently in humans and grows linearly with age. This may be related to prolonged human exposure to the viral hepatitis [
Nephropathies were found in 13.1% of our patients. Ouattara et al. [
Peritoneal tuberculosis counted for 6.7% of the causes of ascites in our study. This prevalence is likely to be underestimated. Indeed, PCR (GenXpert) was performed in patients according to the diagnostic orientation. Bambara [
We noted 5% of indeterminate cases. No laparoscopy had been performed due to the unfavorable technical background and the limited financial resources of the patients. This exam could show granulomatosis diseases of peritoneum.
Our study allowed us to have an overview of the clinical and etiological aspects of ascites in the Departmental University Hospital of Porto-Novo. This etiologi- cal diversity must therefore impose a rigorous diagnostic approach. Careful inquisition should seek the patient’s antecedents and related ascites symptoms, which have an etiological orientation value. Physical examination should not be restricted to the digestive tract as the cause may be extra digestive. These two steps will allow a difficult selection of the paraclinical examinations according to the orientation of the diagnosis.
Sehonou, J., Wanvoegbe, F.A., Kpossou, A.R., Agbodande, K.A., Dossou, J., Attinsounon, A., Alassani, A., Azon-Kouanou, A., Dovonou, A., Zannou, M. and Houngbe, F. (2017) Clinical and Etiological Profile of Ascites in the Departmental University Hospital of Porto-Novo. Open Journal of Gastroenterology, 7, 197- 205. https://doi.org/10.4236/ojgas.2017.77021