Ascites

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 17–7)

• 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)

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 from hepatic encephalopathy

• 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 with hypoalbuminemia: anasarca

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

Differential Diagnosis

• See Table 17–7

• 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 ...