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Key Features

Essentials of Diagnosis

  • Pathologic accumulation of fluid in the peritoneal cavity

General Considerations

  • Two broad categories of ascites

    • Associated with a normal peritoneum

    • Due to a diseased peritoneum (Table 15–7)

  • Most common cause is portal hypertension secondary to chronic liver disease (> 80% of cases)

  • Other causes

    • Infections (tuberculous peritonitis)

    • Intra-abdominal malignancy

    • Inflammatory disorders of the peritoneum

    • Ductal disruptions (chylous, pancreatic, biliary)

  • Risk factors for ascites include causes of liver disease

    • Alcohol consumption

    • Transfusions

    • Tattoos

    • Injection drug use

    • History of viral hepatitis or jaundice

    • Birth in an area endemic for hepatitis

  • History of cancer or marked weight loss suggests malignancy

  • Fevers suggest infected peritoneal fluid, including bacterial peritonitis (spontaneous or secondary)

Table 15–7.Causes of ascites.

Clinical Findings

Symptoms and Signs

  • Increasing abdominal girth

  • Abdominal pain

  • In portal hypertension: large abdominal wall veins with cephalad flow; inferiorly directed flow implies hepatic vein obstruction

  • In portal hypertension and chronic liver disease

    • Palmar erythema

    • Cutaneous spider angiomas

    • Gynecomastia

    • Muscle wasting

  • Asterixis secondary to hepatic encephalopathy may be present

  • In right-sided heart failure or constrictive pericarditis: elevated jugular venous pressure

  • In acute alcoholic hepatitis or Budd-Chiari syndrome: large tender liver

  • In cardiac failure or nephrotic syndrome: anasarca

  • In malignancy: firm lymph nodes in the left supraclavicular region or umbilicus

Differential Diagnosis

  • See Table 15–7

  • Cirrhosis

  • Malignancy

  • Heart failure

  • Tuberculous peritonitis

  • Dialysis-related

  • Bile or pancreatic ascites

  • Lymphatic tear (chylous ascites)

  • Nephrotic syndrome

Diagnosis

Laboratory Tests

  • Ascitic fluid cell count: normal cell count is < 500 leukocytes/mcL and < 250 polymorphonuclear neutrophils (PMNs)/mcL

  • PMN count of > 250/mcL (neutrocytic ascites), with > 75% of all white blood cells (WBCs) being PMNs usually indicates bacterial peritonitis

  • Ascitic fluid culture ...

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