Ascites Causes, Diagnosis, Treatment, Management —

Ascites is presence of free fluid in the abdomen (peritoneal cavity). Symptoms of ascites are Bloating, fullness in abdomen, Increased pressure, Indigestion, Stretching, pulling, Localized pain, Low back pain, Heart burn, Dyspnea, orthopnea, tachypnea, Hernias, etc.

Defination of ascites — 

• In medical words Ascites is the accumulation of fluid (most commonly serous fluid, which is a light yellow and clear fluid in appearance) in the abdominal peritoneal cavity.
• Abdominal cavity is Placed below the chest cavity, diaphragm separated it from it from chest cavity. Ascitic fluid may have different causes such as liver disease, cancers, congestive heart failure, kidney failure, etc.
• Ascites is presence of free fluid in the abdomen (peritoneal cavity).

Abdomen looks swollen if there is any cause —

• · Sensation of fullness in abdomen
• · Local type swelling on abdomen
• · Obesity common
• · Lumbar lordosis [ abnormal forward curvature of the spine ]
• · Ascites.

Symptoms of ascites —

• Bloating, fullness in abdomen
• Stretching, pulling
• Low back pain
• Localized pain
• Increased pressure
• Indigestion
• Heart burn
• Dyspnea, orthopnea, tachypnea
• Hernias, etc.

Physical Examination

• In Ascites-tense abdomen, bulging flanks, stretched skin, everted umbilicus.
• Palmar erythema (red palm) and spider nevi in cir­rhosis.
• Supraclavicular lymph nodes-Virchow’s node in gas­trointestinal malignancy.
• Prominent abdominal veins with flow away from um­bilicus in portal hypertension, flow from lower part of abdomen to umbilicus in inferior vena cava obstruc­tion, flow down to umbilicus in superior vena cava obstruction.
• Bowel loops with doming of abdomen seen in intesti­nal obstruction.
• Epigastric mass with peristalsis left to right seen in pyloric obstruction.

Palpation

• · Ballottement test for fluid – sudden, deep movement with hands.
• · Splenomegaly may present
• · Liver – Soft in extrahepatic portal hypertension – Firm in Cirrhosis
• – Hard in malignancy
• · Hard periumbilical nodule – Sister Mary Joseph’s nodule) in metastatic disease from pelvic or gas­trointestinal tumor.
• .Pulsate liver and ascites in TR (Tricuspid Re­gurgitation).
• Mass: Solid, cystic, moves with respiration or not.
• Liver, spleen, gal! bladder move with respiration. Retroperitoneal mass does not.
• Tenderness means abscess.

percussion —-

• · Fluid in the abdomen is dull on percussion.
• · For small amount fluid, patient is put on hands and knees.
• .Liver dullness is absent in cirrhosis, perforation of gut.
• · Shifting dullness: area of dullness shifts with change in posture of patient.
• Fluid thrill is present.
• by Ultrasound can detect as little as 100 ml of fluid.

Auscultation

• High-pitched rushing sounds in early obstruction. Bruit sound over liver in vascular tumor, hepatocellular carcinoma may present.
• Leathery friction rub of surface nodule.
• Venous hum at umbilicus in portal hypertension.

Rectal examination, pelvic examination—

X-ray:

• Upright films – Fluid levels and dilated intestinal loops are seen.
• Recumbent films – Diffuse haziness, loss of psoas margins. Liver abscess, liver carcinoma may be diagnosed.

Ultrasound –

• any abnormal mass, organs seen.

CT Scan To see:

• – Retroperitoneu m
• – Pancreas
• – Lymph node.
• Barium study of cancers/ tumours.

CAUSES OF ASCITES —

• Tuberculosis
• · Cirrhosis of liver
• · CHF (Congestive Heart Failure)
• · Anemia with hypoproteinemia
• · Nephrotic syndrome
• · Carcinomatosis
• · Hepatocellular carcinoma
• · Portal vein thrombosis
• · Bacterial peritonitis.

DIAGNOSTIC PARACENTESIS

• · Remove 50 – 100 ml fluid
• : – Gross appearance – Protein content
• – Cell count
• – Differential cell count
• – Gram’s stain
• – AFB stain.

SAG – Serum Albumin Gradient —

• Serum: ascites albumin gradient if more the 1.1 gjdl (high gradient) suggests uncomplicated cirrhosis (as­cites due to portal hypertension).
• If SAG < 1.1 g/dl (low gradient) suggests that ascites is not due to portal hypertension.
• In other words, if ascitic fluid albumin is more than serum albumin then ascites is not due to portal hy­pertension but some other etiology. If serum albumin is more than ascitic fluid albumin then the cause is portal hypertension as in cirrhosis of liver.
• Blood stained fluid may be seen in neoplasm or tu­bercular peritonitis.
• Cloudy fluid with increased polymorphs (with +ve Gram’s stain) in bacterial peritonitis.
• Most cells are lymphocytes in tubercular peritonitis. Culture of peritoneal fluid – for microorganisms

Biopsy —

• Laparoscopy of peritoneum – visualization and biopsy.

Chylous ascites

• · Turbid or milky peritoneal fluid.
• · Sudan-staining fat globules and increased trig­Iycerides (> 1000 mgjdl).
• · If turbidity clears with alkali, it is due to cellular protein.
• ·If turbidity clears with ether, it is due to lipids.

Causes of Chylous fluids —

• · Filariasis
• · Tuberculosis
• · Trauma
• · Tumors
• · Nephrotic syndrome.

Mucinous Ascites

• Pseudomyxoma peritoneii.
• Colloid carcinoma of stomach or colon.

Ascitic fluid- may be —

1–Transudate Cirrhosis

• Venous hypertension Hypoalbuminemia Nephrosis
• Tricuspid regurgitation, RVF Constrictive pericarditis Meig’s syndrome (ascites, hydrothorax, ovarian tumors)

2–Exudate

• Bacterial peritonitis Tubercular peritonitis

Other investigations —

• · Doppler ultrasound
• · Angiography
• · CT
• · MRI
• · Endoscopic retrograde graphy (ERCP).

This is short description about ascites if you have any question about it feel free to make a comment i will reply it as soon as possible.