ASCITES

1
ASCITES R. MICHAEL RODRIGUEZ, M.D. ASSOCIATE
PROFESSOR OF MEDICINE VANDERBILT UNIVERSITY
SCHOOL OF MEDICINE
2
ASCITES
DEFINITION FREE FLUID IN THE ABDOMINAL CAVITY
JAMA 19922672645-2648
3
PATHOPHYSIOLOGY OF ASCITES

• HYDROSTATIC PRESSURE
• CIRRHOSIS
• CHF
• CONSTRICTIVE PERICARDITIS
• OSMOTIC PRESSURE
• NEPHROTIC SYNDROME
• MALNUTRITION
• PROTEIN LOSING ENTEROPATHY
• FLUID PRODUCTION EXCEEDING RESORPTIVE CAPACITY
• INFECTION TB
• MALIGNANCY

JAMA 19922672645-2648
4
HISTORY
USEFUL

• H/O INCREASED ABDOMINAL GIRTH
• H/O PEDAL EDEMA
• H/O WEIGHT GAIN
• H/O CHF
• H/O HEPATITIS
• H/O ETOH
• H/O MALIGNANCY

NOT AS USEFUL
JAMA 19922672645-2648
5
BULGING FLANKS
ASCITES OR OBESITY?
JAMA 19922672645-2648
6
SHIFTING DULLNESS
METHOD OF EXAMINATION BEGIN BY PERCUSSING AT THE
UMBILICUS AND MOVING TOWARD THE FLANKS. THE
TRANSITION FROM AIR TO FLUID CAN BE IDENTIFIED
WHEN THE PERCUSSION NOTE CHANGES FROM TYMPANIC TO
DULL. ROLL THE PATIENT ON THEIR SIDE AND PERCUSS
AS BEFORE. THE AREA OF TYMPANY WILL SHIFT TOWARDS
THE TOP AND THE AREA OF DULLNESS TOWARDS THE
BOTTOM.
JAMA 19922672645-2648
7
SHIFTING DULLNESS
PATIENT OR ASSISTANT
TAP
FEEL
METHOD OF EXAMINATION HAVE THE PATIENT OR
ASSISTANT PLACE THEIR HANDS IN THE MIDLINE TAP
ONE FLANK SHARPLY AND USE THE FINGERTIPS OF THE
OPPOSITE HAND TO FEEL FOR AN IMPULSE ON THE
OPPOSITE FLANK
JAMA 19922672645-2648
8
PUDDLE SIGN
METHOD OF EXAMINATION PATIENT IS PRONE FOR 3-5
MINUTES AND THEN RISES TO ALL FOURS DIAPHRAGM OF
THE STETHOSCOPE IS PLACED OVER MOST DEPENDENT
AREA OF THE ABDOMEN BEGIN BY FLICKING A FINGER
OVER A LOCALIZED FLANK AREA MOVE THE STETHOSCOPE
OVER THE OPPOSITE FLANK SUDDEN INCREASE IN
INTENSITY IS A POSITIVE SIGN (NO LONGER USED)
JAMA 19922672645-2648
9
SUMMARY

• HISTORY
• PERFORM APPROPRIATE EXAMINATION TO DIAGNOSE
  ASCITES
• PUDDLE SIGN IS NO LONGER USED