The physical examination in a patient with ascites should focus on the signs of portal hypertension and chronic liver disease. Ascites is the accumulation of ascitic fluid in the peritoneal cavity. In the united states, ascites is most often due to portal hypertension resulting from cirrhosis. Physicians should be familiar with the signs of ascites and physical examination maneuvers that can be. This can make the abdomen belly enlarge like a balloon filled with water. Ascites is a symptom that may have important diagnostic, prognostic, and therapeutic implications. The main complications of cirrhosis are related to the. The sensitivity of these maneuvers is limited by the amount of peritoneal fluid present, and ultrasound is useful in defining small amounts of fluid. Furthermore, a subgroup of patients maybe intolerant to augmented medical management given symptomatic or biochemical sideeffects, and thus classified as diureticintractable ascites 74, 76, 77. Obesity, hypercholesterolemia, and type 2 diabetes mellitus are recognized causes of nonalcoholic steatohepatitis, which can progress to cirrhosis. The mechanism of ascites in cirrhosis is complex but portal hypertension and renal sodium retention is common. Cirrhosis and its complications are among the top 10 causes of death in the united states. Patients with ascites who have a history of cancer should be suspected of having malignancyrelated ascites.
Ascites is the accumulation of fluid within the abdomen. Ascites is a major complication of cirrhosis, 1 occurring in 50% of patients over 10 years of follow up. Cirrhosis is the pathologic endstage of any chronic liver disease and most commonly results from chronic hepatitis b and c, alcoholrelated liver disease, and nonalcoholic fatty liver disease. Fluid leaks out into the belly and begins to fill it up. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. If observed for 10 years, approximately 60% of patients with cirrhosis develop ascites requiring therapy. Fetuses presenting with generalized hydrops were excluded. Workup history the history can help to elucidate the cause of ascites formation. Is there any shortness of breath due to fluid accumulation, or ascites. A clue is frequently an inappropriately high white cell count in otherwise transudative ascites. Ascites does not typically become clinically detectable until there are at least 500mls of fluid present. History should also include past abdominal surgeries. This guide structures the history in parallel with the structure of the gi system, beginning at the mouth and working downwards. Quantity and duration has ascites diminishedresolved intermittently in relation to abstinence from alcohol.
Accumulation of fluid within the peritoneal cavity results in ascites. Ascites, refractory ascites and hyponatremia in cirrhosis. Guidelines on the management of ascites in cirrhosis. Iv drug use tattoos acupuncture sexual history travel history, where born family history wilsons disease, hemochromatosis. View our ascites patient fact sheet for more information. In advanced cases, such as refractory ascites, serial lvp with albumin and, in some patients, tips placement may need to be considered. History taking and physical examination for the patient. A basic analysis of ascitic fluid albumin can be instructive when compared to serum albumin as the saag where. Aki in a patient with cirrhosis and ascites american. The focus of history taking and the physical examination varies depending on the context of the clinical evaluation.
Introduction ascites is defined as the pathological accumulation of fluid in the peritoneal cavity. Patients with a history of cancer, especially gastrointestinal cancer, are at risk for malignant ascites. Ask the patient if they received treatment and if the treatment was successful. If large amounts of fluid accumulate, the abdomen can. Analyze and interpret the assembled clues to reach the provisional diagnosis. Diagnostic paracentesis and abdominal sonogram should. The history shows that cirrhotic ascites progresses from diuretic responsive uncomplicated ascites to the development of dilutional hyponatraemia, refractory ascites, and finally, hepatorenal syndrome hrs. Cancer in the past, however, does not guarantee a malignant cause of ascites. A classification of the causes of abdominal distension is presented in table 20.
Cirrhosis of the liver is the most common cause of ascites but other conditions such as heart failure, kidney failure, infection or cancer can also cause ascites. Easl clinical practice guidelines for the management of. Taking a good history is also important in order to look for any issues with patient compliance, ingestion of offending medications or consumption of alcohol. Ascites is a distressing symptom that requires demanding treatments, such as taking diuretics, reducing dietary salt or fluid intake, and draining ascitic fluid out of the abdomen paracentesis. Past gastrointestinal disease and medication history. Include a history of alcohol use abuse, past and present. History and physical examination in the united states, in approximately 85% of patients with ascites, cirrhosis is the cause, but 15% have a non hepatic cause of fluid accumulation figure 2. Personal data name, address, date of birth, referring physician, next of kin 2. The decreased sodium excretion is predominantly caused by arterial vasodilation. Ascites is the most common major complication of cirrhosis and is an important landmark in the natural history of chronic liver disease. The prognosis the life expectancy depends on the cause of. In the patient with acute or chronic liver injury, jaundice, or known chronic liver disease, the patients history and physical examination findings provide important information to guide further evaluation and management. The natural history of cirrhotic ascites progresses from diuretic responsive uncomplicated ascites to the development of dilutional hyponatraemia, refractory ascites, and.
Cirrhotic ascites forms as the result of a particular sequence of events. Assessment for ascites centers for disease control and. Blood clots in the veins that enter and leave the liver. Malignant ascites ma is a sign of advanced cancer and poor prognosis. General history taking taking the history of a patient is the most important tool you. Many diseases can cause ascites, but the most common is portal hypertension, which is usually due to cirrhosis. Ascities treatment guidelines depend upon the condition causing ascites. When this happens, the condition is called spontaneous bacterial peritonitis. History taking and physical examination for the patient with. Patients who develop ascites in the setting of established diabetes or nephrotic syndrome may have nephrotic ascites.
When clinically detectable, ascites may indicate underlying heart failure, liver disease, nephrotic syndrome, or malignancy. Ascites may go away with a low salt diet, and with diuretics water pills ordered by your provider. In addition, about 50 percent of patients with cirrhosis will develop ascites within 10 years. Assessment for ascites physicians should be familiar with the signs of ascites and physical examination maneuvers that can be used to detect ascites.
Once ascites develops, the probability of survival at 5 years is only 44%. Common causes of ascites are liver disease or cirrhosis, cancers,and heart failure. Mixed ascites occurs in 5% of cases when the patient has two or more separate causes of ascites formation, usually due to cirrhosis and infection or malignancy. Over time you will stop using this approach and only ask a smaller more focused subset of these questions. The use of us to diagnose ascites has been supported by the fact that physical examination findings, like shifting dullness and a palpable fluid wave, have only an intermediate diagnostic sensitivity 70% 80% due to the larger volumes of ascites required for a relia. Ascites is the buildup of an abnormal amount of fluid inside the abdomen belly. It is also often a sign that liver cirrhosis has progressed from a stable to a decompensated state and patients with decompensated liver cirrhosis. Malignancyrelated ascites is frequently painful, whereas cirrhotic ascites is usually painless. While 1 year survival in patients who develop ascites is 85%, it. Ascites is the buildup of an abnormal amount of fluid inside the belly. Make a differential diagnosis of all possible complications. Other common causes include malignancy and heart failure.
The duration of abdominal distension and its association with abdominal pain are key questions. In this attending rounds paper, a patient with oliguric aki is presented to emphasize the role of laboratory and bedside tests that can establish a correct diagnosis and lead to appropriate management. To be able to obtain a history that is targeted to the presenting complaint takes practice, as well as knowledge of possible differential diagnoses. Ascitic fluid analysis ascites interpretation geeky medics. For example, patients with tobaccorelated lung cancer and a history of alcohol abuse may have ascites due to cirrhosis. The causes and natural history of fetal ascites zelop. Cirrhotic ascites primarily develops due to impaired renal sodium excretion leading to a positive sodium balance and hence water retention, causing expansion of the extracellular fluid volume. An elevated ascitic fluid amylase level would be very suggestive for pancreatic ascites, e. Ascites and spontaneous bacterial peritonitis clinical gate. Ma can result in impairment in quality of life qol and significant symptoms. The natural history of cirrhosis is characterised by an asymptomatic compensated phase followed by a decompensated phase, marked by the development of overt clinical signs, the most frequent of which are ascites, bleeding, encephalopathy, and jaundice.
Fluid accumulation in the abdomen was recognized in ancient times. Case scenario definition of ascites causes of ascites. But sometimes a provider must drain the fluid from the belly using a special needle. Signs and symptoms of ascities include shortness of breath, and abdominal pain, discomfort, or bloating. Dec 29, 2017 patients with a history of cancer, especially gastrointestinal cancer, are at risk for malignant ascites. May 27, 20 an elevated ascitic fluid amylase level would be very suggestive for pancreatic ascites, e.
While there are a number of conditions that can cause it, approximately 75 percent of patients with ascites also have cirrhosis of the liver. Ascites ascites is one of the most common complications of cirrhosis. Physical examination can provide clues to the cause of ascites in a given patient. Gastrointestinal history taking requires a systematic approach to ensure you dont miss anything important. Approach to the patient with ascites differential diagnosis. Successful treatment of ascites depends upon an accurate diagnosis of its cause table 1 and table 2 and table 3 and. Ascites may make it difficult to eat because there is less. A small population of ascites patients may be defined as having refractory ascites. This chapter details important history taking and physical examination findings to be applied to jaundiced patients. Ascites fluid in the belly viral hepatitis and liver disease. Are there any features suggesting liver disease and. The main complications of cirrhosis are related to the development of liver insufficiency and portal hy.
Medical history a family illnesses parents, siblings, children b prior illnesses in chronologic order. Ascites is accumulation of fluid in the abdominal cavity. Note presence or absence of extrahepatic manifestations of veterans liver disease e. When a patient with a very long history of stable cirrhosis develops ascites, the possibility of superimposed hepatocellular carcinoma should be considered. Cirrhosis symptoms, diagnosis and treatment bmj best practice. Chapter 91 ascites and spontaneous bacterial peritonitis 1519 than usual i. Ascites is treated by lowering salt in the diet and taking water pills. History and physical examination in the united states, in approximately 85% of patients with ascites, cirrhosis is the cause, but 15% have a non hepatic. This is a common problem in patients with cirrhosis scarring of the liver. Social status occupation, family, daily function, 4. Acute deterioration in kidney function in a patient with cirrhosis and ascites presents a difficult management problem, and it is associated with increased mortality. Objectives list the hazards that must be considered when approaching an ill or injured person list the elements to approaching an ill or injured person safely. Initial examination showed abdominal distention and blood tests indicated eosinophilia.
Ultrasound for detection of ascites and for guidance of the. Medical history a family illnesses parents, siblings, children b prior illnesses. Managing ascites another problem caused by high pressure in the veins of the liver is ascites. The diagnosis is generally made by taking a sample from the abdominal cavity as described above ie, by performing a paracentesis. Ascites is caused by a combination of elevated pressure in the veins running through the liver portal hypertension and a decrease in liver function caused by scarring of the liver.
Ask about any past history of gastrointestinal disorders such as ulcers, gall bladder disease, hepatitis, appendicitis, hernias. In this attending rounds paper, a patient with oliguric aki is presented to emphasize the role of laboratory and bedside tests that can establish a correct diagnosis and lead to appropriate. Ascites is a buildup of fluid in your lower abdomen. A common problem in people with cirrhosis american.
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