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Definition
?Accumulation of excess or free fluid within peritoneal cavity.
?Small amounts ? asymptomatic
?Larger amount ( > 1L ) ---
? Abdominal distension
? Fullness in flanks
? Shifting dullness on percussion
?Marked ascites : fluid thrill/wave
?Other features
? Eversion of umbilicus
? Herniae
? Abdominal striae
? Dilated superficial abdominal veins . etc
PATHOPHYSIOLOGY
A state of total-body sodium and water excess.
Portal hypertension
Nitric oxide mediated splanchnic arteriolar vasodilation
Systemic arterial pressure fal s Baroreceptor mediated RAAS activation
Secondary aldosteronism
Normalise arterial P Increased sympathetic activity
Na and water retention Increased atrial natriuretic hormone secretion
Alters intestinal capillary permeability Altered activity of kallikrein-kinin system
Fluid accumulation in peritoneum
Aetiology
?Types :
vTRANSUDATIVE
general y, - low protein concentration(<2.5g/dL)
- serum ascites albumin gradient >1.1 g/dL
- typical in cirrhosis ? portal hypertension
- relatively few cel s
vEXUDATIVE
general y, - high protein ascites (>2.5g/dL)
- SAAG < 1.1 g/dL
- in inflammation or malignancy
- malignant cel s/ PMNL
Causes
CLINICAL CASE TAKING
History
?Children- nephrotic syndrome
?Middle age-liver cirrhosis
?Old age- malignancies, cirrhosis
ORDER OF DEVELOPMENT
? Cirrhosis ?first feature
? Cardiac- pedel edema precedes ascites
? Kidney-puffiness of the face before ascites
? Ascites praecox ?ascites appears disproportionately as wel as before oedema
== seen in ? constrictive pericarditis, a/c budd chiari syndrome, tb peritonitis, malignant
peritonitis
Onset
ACUTE INSIDIOUS
a/c Budd chiari liver cirrhosis
a/c right heart failure tb ascites
Pancreatic ascites nephrotic syndrome
constrictive pericarditis
General examination
?Anemia- CLD
?Jaundice -liver pathology
?Enlarged lymphnode- tb,malignancy,lymphoma
?Oedema- nephrotic syndrome periorbital oedema ,facial puffiness, pedal oedema
?PND , dyspnea, orthopnea- CCF
Inspection
?Abdomen distended
?Umbilicus can be inverted or everted
slit transversely-laughing umbilicus
?Flanks full-1.5L
?Caput medusa -portal hypertension
?Scrotal oedema ?nephrotic syndrome
Palpation
?Tenderness and local rise of temperature-peritonitis
?Enlarged tender liver and ascites-CCF
?Sister joseph nodule ?CA stomach
?Tb peritonitis-doughy feel of abdomen
multiple palpable mass due to matted omentum and loops of intestine
Percussion
? About1 to 1.5L fluid is needed to produce flank dullness
? SHIFTING DULLNESS-supine position
? FLUID THRILL
? PUDDLE SIGN-minimal fluid(120ml)
Shifting dul ness
Fluid thril
Puddle sign
Investigations
Other tests
?TB peritonitis ? peritoneal biopsy, stain and culture for AFB
?Neoplasm ? cytology, cell block, peritoneal biopsy
?Pyogenic ? gram stain , culture
?Chylous ? ether extraction, Sudan staining
?Pancreatic ascites ? increased amylase
THANKYOU
This post was last modified on 12 August 2021