Ascites knowledge for medical students and physicians. An adequate clinical assessment should be followed by imaging e. The word ascites is derived from the greek askos and askites meaning bag, bladder, or belly. Abdominal examination osce guide new release youtube. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Jan 12, 2018 clinical examination palpation of the spleen by prof. For the best exam, make sure the patient is warm and comfortable. An elevated temperature would signify an underlying infectious or inflammatory condition such as bacterial tuberculosis. Ascites is the pathologic accumulation of excess fluid in the peritoneal cavity. European association for the study of the liver 2010 easl clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis.
In clinical practice, the term ascites refers to the. Learn more dengue clinical case management e learning merging and zoonotic infectious diseases assessment for ascites physicians should be familiar with the signs of ascites and physical examination maneuvers that can be used to detect ascites. Treatment, complications, and prognosis intechopen. The liver may be difficult to palpate if a large amount of ascites is present, but if palpable, the liver is often found to be enlarged. Ascites is the buildup of fluid in the space between the lining of the abdomen and abdominal organs. The sensitivity of these maneuvers is limited by the amount of peritoneal fluid present, and ultrasound is useful in defining small amounts of fluid. Several maneuvers for examining the liver and for detecting ascites are described in this module. When it is important to detect smaller amounts of peritoneal fluid, radiologic images will be necessary because the clinical examination will not be useful, which is especially important when evaluating for abdominal malignancies or for patients with blunt abdominal trauma. Hepatorenal syndrome hrs is a functional, reversible form of acute kidney injury in patients with acute or chronic severe liver disease in the absence of any other identifiable causes of renal pathology. Good manufacturing practices for pharmaceuticals, seventh edition this book provides insight into the world of pharmaceutical quality systems and the key elements that must be in place to change the business and organizational dynamics from taskoriented procedurebased cultures to truly integrated quality business systems that are selfdetecting and correcting. A pleural effusion is found in a small percentage of patients with ascites, usually on the right side. The overall accuracy of the maneuvers was only 58%. Pediatric hepatorenal syndrome clinical presentation.
Clinical examination of the cardiovascular system by, dr. Palpation and percussion of the liver are important techniques for identifying hepatomegaly. In heart failure, physical examination findings may include jugular venous. If the fluid is less, ultrasound of abdomen, ct or mri of abdomen are helpful to know the amount of fluid in abdomen and also to know the condition of liver, kidneys, any cancers etc. History and physical examination, 10th edition current. The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical. Patients with newonset ascites should receive diagnostic paracentesis consisting of cell count, total protein test, albumin level, and bacterial culture and sensitivity. Aug 12, 2009 the black book of clinical examination by hong liang tey, 9780071268363, available at book depository with free delivery worldwide. The condition is characterized by peripheral vasodilation with subsequent profound intrarenal vasoconstriction, resulting in decreased glo.
Ascites is a pathologic accumulation of peritoneal fluidcommonly observed in decompensated cirrhotic states. Bates guide to physical examination and history taking. Ascites is the most common complication in patients with cirrhosis. May 27, 20 a diagnostic paracentesis, as opposed to a therapeutic paracentesis vida infra, requires approximately 3050 ml, and is mandatory in all cases of new onset ascites or ascites occurring in an individual with a change in clinical status to include fever, abdominal pain, new onset or worsening he and any sign or symptom of infection generally. Physical examination inspection, palpation, percussion, auscultation, vital signs, weight, height 3. It is with great pride that we present to you the sixth edition of clinical examination. When ascites collects, the influence of gravity causes it first to accumulate in the flanks of a supine patient. Approximately 10% of patients with ascites have a malignancy as the primary cause runyon et al. Included on the student consult site are the speciallyrecorded videos demonstrating many of the clinical examination routines described in the main text. Because most ascites is secondary to chronic liver disease with portal hypertension, patients should be asked about risk factors for liver disease, especially alcohol consumption, transfusions, tattoos, injection drug use, a history of viral hepatitis or jaundice, and birth in. The accuracy of the physical examination in the diagnosis.
The book starts with a general overview section on history taking and the general examination that provides the framework on which to hang the detail. The abdominal examination is conventionally split into four. Thus, cirrhosis should be considered in patients with liver disease who have either abnormal laboratory tests or clinical features compatible with the morphological changes of cirrhosis that disturb hepatic function. Complications can include spontaneous bacterial peritonitis in the developed world, the most common cause is liver cirrhosis. Approach the examination of the liver from the right side of the patient. When clinically detectable, ascites may indicate underlying heart failure, liver disease, nephrotic syndrome, or malignancy. Aug 27, 2014 clinical features of marked abdominal swelling gross ascites dull in flanks umbilicus everted andor hernia present shifting dullness positive fluid thrill positive large ovarian cyst resonant in flank umbilicus, vertical and drawn up large swelling felt arising out of pelvis which one cannot get below intestinal obstruction resonant.
National institute for health and clinical excellence interventional procedures. Ascites and the acquired immunodeficiency syndrome. Infections bacterial, tuberculous, fungal, parasitic, neoplasms, connective tissue disease, miscellaneous whipples disease, familial mediterranean fever, endometriosis, starch. The ufhscj is a clinical teaching site for the gainesvillebased college of nursing. Mcgahren iii, in pediatric surgery seventh edition, 2012.
A rare clinical presentation of carcinoma cervix ascites article pdf available in indian journal of pharmacy practice 43. Clinical examination palpation of the spleen by prof. The signs of liver disease are for the most part to be found outside the abdomen. Ascites is detected with physical examination of the abdomen by visible bulging of the flanks in the reclining person flank bulging, shifting dullness difference in percussion note in the flanks that shifts when the person is turned on the side, or in massive ascites, with a fluid thrill or fluid wave tapping or pushing on one side. The puddle sign may be present when as little as 120 ml of fluid is present. The current edition is also missing common topics seen in ward medicine. The physical examination typically occurs after a thorough medical history is taken, that is, after the physician asks the patient the course of their symptoms. Diagnostic method physical exam, ultrasound, ct scan. A multicenter, casecontrolled study of the clinical presentation and etiology of ascites and of the safety and clinical efficacy of diagnostic abdominal paracentesis in hiv seropositive patients. Clinical rotations in all the major disciplines are provided for ufcom undergraduate medical students and elective rotations to students from other accredited schools. Pdf a rare clinical presentation of carcinoma cervix ascites. This can often be determined by the history and physical examination, but paracentesis is diagnostic. These maneuvers may not help you to discriminate well between a normal and an inflamed appendix, but they may help to identify an inflamed appendix atypically located within the pelvic cavity. Its causes are multifactorial, but principally involve significant volume and hormonal dysregulation in the setting of portal hypertension.
Ascites ultrasonographic diagnosis nova science publishers. Blood investigations are helpful to determine the underlying cause of ascites. Inspection consists of visual examination of the abdomen with note made of the. When peritoneal fluid exceeds 500 ml, ascites may be demonstrated by the presence of shifting dullness or bulging flanks. Abdominal distention is the most common physical finding associated with ascites. The sensitivity of these maneuvers is limited by the amount of peritoneal fluid. They may also suggest other causes of the abdominal pain. Ascites there are several physical examination maneuvers described for detection of ascites described below that are at least moderately sensitive and specific.
This book is distributed under the terms of the creative commons. The book has been in continuous production for over 20 years and remains one of the most successful textbooks on examination methods in the world today. Ascites may be associated with abdominal pain in rare cases. Inspection, auscultation, palpation, and percussion of the abdomen. Samples of peritoneal fluid should be sent to the laboratory for protein concentration, specific gravity, cell counts, and culture. No single maneuver is both highly sensitive and specific. Do not perform any examination or procedure on patients based purely upon the.
Physical examination can provide clues to the cause. The accuracy of the physical examination in the diagnosis of suspected ascites. The liver is enlarged in a number of important clinical diagnoses. In the united states, in approximately 85% of patients with ascites, cirrhosis is the cause, but 15% have a nonhepatic cause of fluid accumulation. The evidencebased examination techniques put forth by rational clinical examination is the sort that can be brought to bear on a daily basis to save time, increase confidence in medical decisions, and help decrease unnecessary testing for conditions that do not require absolute diagnostic certainty. Proper history and physical examination are important in diagnosing the cause. Ascites is the abnormal accumulation of fluid in the peritoneal cavity. These laboratory findings typically occur before the physical examination manifestations of cirrhosis. Perform a rectal examination and, in women, a pelvic examination.
Other conditions resulting in ascites include chronic heart failure, visceral inflammation e. The black book of clinical examination by hong liang tey, 9780071268363, available at book depository with free delivery worldwide. The goal of this stanford medicine 25 session is for you to be able to list these signs from head to foot. This page includes the following topics and synonyms. Shifting dullness an overview sciencedirect topics. Ascites is due to the loss of compensatory mechanism to maintain effective arterial blood volume secondary to splanchnic arterial vasodilatation in the progression of liver disease and portal hypertension. Assessment of the patient with ascites current medical. Evaluation should include rectal and pelvic examination, assessment of liver and spleen. Additionally, examination of the abdomen can reliably indicate fluid in the peritoneal cavity is present. Ascites describes an abnormal collection of fluid in the peritoneal cavity. Preserve the patients privacy by draping the top of their body with the gown and below the waist with a sheet. The majority of patients with ascites have advanced liver diseaseusually cirrhosis runyon, montano, akriviadis et al. Your doctor will be able to diagnose ascites with clinical examination. Ascites is the abnormal buildup of fluid in the abdomen.
Ascites is a major complication of cirrhosis,1 occurring in 50% of patients over 10 years of follow up. An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. Two further techniques help to confirm the presence of ascites, although both signs may be misleading. Ascites is a pathological accumulation of fluid in the peritoneal cavity. Patients with obesity can be distinguished from those with ascites by careful examination. Oct 06, 2018 always adhere to your medical schoollocal hospital guidelines when performing examinations or clinical procedures. Hemorrhagic ascites clinical presentation and outcomes. Physical examination of patients with ascites is usually remarkable for flank dullness, shifting dullnes, and fluid wave. Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Always adhere to your medical schoollocal hospital guidelines when performing examinations or clinical procedures.
Ascites is a symptom that may have important diagnostic, prognostic, and therapeutic implications. The authors, who have many years of experience coaching candidates for undergraduate and postgraduate examinations, stress the significance of important steps and relevant signs, highlight common errors, and provide useful advice to guide the student through the morass of information that is apt to trap the. Treatment, lowsalt diet, medications, draining the fluid. Other nonmalignant diseases associated with ascites include rightsided heart failure, tuberculous peritonitis, nephrotic syndrome, complications of pancreatitis, and chylous ascites from trauma. Ascites is the abnormal accumulation of fluid in the peritoneal cavity and a common complication of diseases presenting with portal hypertension e. Percuss and mark the borders more dependent side, while tymagain. When it is important to detect smaller amounts of peritoneal fluid. Simel, md, mhs chief, medicine service durham veterans affairs medical center professor of medicine duke university school of medicine durham, north carolina drummond rennie, md jama chicago, illinois philip r. The sensitivity and specificity of the physical examination maneuvers ranged from 50% to 94% and 29% to 82%, respectively. Packed with expert knowledge and practical guidance it gives realistic advice on coping with common situations. After mapping the borders of tympany and dull in ascites, dullness shifts to the ness, ask the patient to turn onto one side. I hope by the end of this book that the medical practice in a case of ascites is. The history usually is one of increasing abdominal girth, with the presence of abdominal pain depending on the cause. Clinical breast exam, triple test score, basal body temperature, cervical mucus, ovulation, menstrual bleeding, menstrual cycle, pelvic nerve innervation.
Technically, it is more than 25 ml of fluid in the peritoneal cavity. Examination is a chapter in the book, gynecology, containing the following 8 pages. The black book of clinical examination mcgrawhill education. Assessment for ascites centers for disease control and. Among patients with liver disease, many findings are useful for assessing the likelihood of cirrhosis. Thus, a relatively early sign of ascites when at least two litres of fluid have accumulated is a dull percussion note in the flanks. The clinical significance of ascites is based largely on its etiology. Fully updated and revised for its second edition, the oxford handbook of clinical examination and practical skills is the only truly comprehensive pocket guide to all aspects of history taking, physical examination, practical procedures, data interpretation, and communication skills. Dec 29, 2017 the liver may be difficult to palpate if a large amount of ascites is present, but if palpable, the liver is often found to be enlarged. The results of this study indicate that routine physical examination has definite limitations in the precise diagnosis of equivocal ascites. The rational clinical examination evidencebased clinical diagnosis editors david l. Another physical sign of ascites is demonstration of a transmitted fluid wave. Cardiac ascites, peritoneal carcinomatosis, and mixed ascites resulting from cirrhosis and a second disease account for 1015%. Inspection, auscultation, palpation, and percussion of the.
Longterm therapy and retreatment of hepatorenal syndrome type 1 with ornipressin and dopamine. A rare clinical presentation of carcinoma cervix ascites. During the general physical examination, patients should not be evaluated for ascites. This book takes the medical student through the steps of a basic clinical examination. The presence of decreased breath sounds or dull percussion in lower chest on physical examination is diagnostic of pleural effusion beside ascites. Clinical features include progressive abdominal distension, shifting dullness, and a positive fluid wave test. Clinical features of marked abdominal swelling gross ascites dull in flanks umbilicus everted andor hernia present shifting dullness positive fluid thrill positive large ovarian cyst resonant in flank umbilicus, vertical and drawn up large swelling felt arising out of pelvis which one cannot get below intestinal obstruction resonant. Oxford handbook of clinical examination and practical skills. Pathogenesis, diagnosis, and treatment is the only book of its kind to focus on the clinical management of ascites and related disorders in patients with chronic liver disease. When it is important to detect smaller amounts of peritoneal fluid, radiologic images will be necessary because the clinical examination will not be useful, which is especially important when evaluating for abdominal malignancies.
411 852 1239 933 582 1467 334 1285 1226 159 1501 1378 61 388 1467 1394 709 1487 155 135 582 1291 1084 988 1062 1092 664 462 1377 54 59 1219 252 1260 430 149