Definition
?Accumulation of excess or free fluid within peritoneal cavity.
?Small amounts ? asymptomatic
?Larger amount ( > 1L ) ---
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? Abdominal distension? Fullness in flanks
? Shifting dullness on percussion
?Marked ascites : fluid thrill/wave
?Other features
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? Eversion of umbilicus? Herniae
? Abdominal striae
? Dilated superficial abdominal veins . etc
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PATHOPHYSIOLOGY
A state of total-body sodium and water excess.
Portal hypertension
Nitric oxide mediated splanchnic arteriolar vasodilation
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Systemic arterial pressure fal s Baroreceptor mediated RAAS activationSecondary 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
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Fluid accumulation in peritoneumAetiology
?Types :
vTRANSUDATIVE
general y, - low protein concentration(<2.5g/dL)
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- 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)
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- SAAG < 1.1 g/dL- in inflammation or malignancy
- malignant cel s/ PMNL
Causes
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CLINICAL CASE TAKING
History
?Children- nephrotic syndrome
?Middle age-liver cirrhosis
?Old age- malignancies, cirrhosis
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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
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== seen in ? constrictive pericarditis, a/c budd chiari syndrome, tb peritonitis, malignantperitonitis
Onset
ACUTE INSIDIOUS
a/c Budd chiari liver cirrhosis
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a/c right heart failure tb ascitesPancreatic ascites nephrotic syndrome
constrictive pericarditis
General examination
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?Anemia- CLD?Jaundice -liver pathology
?Enlarged lymphnode- tb,malignancy,lymphoma
?Oedema- nephrotic syndrome periorbital oedema ,facial puffiness, pedal oedema
?PND , dyspnea, orthopnea- CCF
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Inspection
?Abdomen distended
?Umbilicus can be inverted or everted
slit transversely-laughing umbilicus
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?Flanks full-1.5L?Caput medusa -portal hypertension
?Scrotal oedema ?nephrotic syndrome
Palpation
?Tenderness and local rise of temperature-peritonitis
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?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
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Percussion? About1 to 1.5L fluid is needed to produce flank dullness
? SHIFTING DULLNESS-supine position
? FLUID THRILL
? PUDDLE SIGN-minimal fluid(120ml)
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Shifting dul ness
Fluid thril
Puddle sign
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Investigations
Other tests
?TB peritonitis ? peritoneal biopsy, stain and culture for AFB
?Neoplasm ? cytology, cell block, peritoneal biopsy
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?Pyogenic ? gram stain , culture?Chylous ? ether extraction, Sudan staining
?Pancreatic ascites ? increased amylase
THANKYOU
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