Ascites and abdominal swelling

1. Ascites and abdominal swelling Int jeerawat silasuwanMD

2. Clincal history • progressive increase in belt or clothing size • insidious onset , without pain • coexistent obesity • flank , groins, low back pain • localized pain [ congestived liver, large spleen, or colonic tumor ] • Pain is uncommon in cirrhosis except pancreatitis, HCC,peritonitis

3. Clincal history • Increase intra-abdominal pressure  GERD, dyspnea, orthopnea, tachypnea • Hepatic hydrothorax leakage through lymphatic chanels

4. Physical examination Inspection • Ascites – tensely abdomen,tightly stretched skin , bulging flanks, everted umbilicus • Venuos pattern – obstruction IVC flow lower part to umbilicus - obstruction SVC flow upper part to umbilicus

5. Physical examination Auscultation • High pitched,rushing sound  gut obstruction • Succussion sound increase fluid in hallow viscus • Harsh bruit at liver HCC or vascular tumor,friction rub  liver metastasis • Venous hum at umbilicus portal HT

6. Physical examination Percussion • Generalized abdominal swelling, careful localized swelling uterus mass,ovarian cyst,ditended bladder • Shifting dullness

7. Shifting dullness

8. Physical examination Palpation • Sister Mary Joseph nodule

10. Radiographic examinations

19. Chylous ascites • Turbid,milky,creamy • Sudan staining fat globule • Increase TG >1000 mg/dL • Pseudochylous  WBC, tumor • Test  alkali lysis cell • Lymphatic obstruction-> trauma,tumor,TB,filariasis,nephrotic syndrome

20. Mucinous ascites • Pseudomyxoma peritonei • Rare colliod CA

21. SAAG > 1.1 mg/dl Cirrhosis Alcoholic Hepatitis Cardiac Ascites Massive Liver Metastasis Fulminant Hepatic Failure Budd-Chiari Syndrome Portal Vein Thrombosis Veno-Occlusive Disease Myxedema Fatty Liver of Pregnancy SAAG < 1.1 mg/d Peritoneal Carcinomatosis Tuberculous Peritonitis Pancreatic Ascites Bowel Obstruction Biliary Ascites Posteroperative Lymphatic Leak Serositis in Connective Tissue Disease nephrosis SAAG

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