Chapter 044. Abdominal Swelling and Ascites (Part 1)

Harrisons Internal Medicine Chapter 44. Abdominal Swelling and AscitesAbdominal SwellingAbdominal swelling or distention is a common problem in clinical medicine and may be the initial manifestation of a systemic disease or of otherwise unsuspected abdominal disease. Subjective abdominal enlargement, often described as a sensation of fullness or bloating, is usually transient and is often related to a functional gastrointestinal disorder when it is not accompanied by objective physical findings of increased abdominal girth or local swelling. Obesity and lumbar lordosis, which may be associated with prominence of theabdomen, may usually be distinguished from true increases in the volume...
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Chapter 044. Abdominal Swelling and Ascites (Part 1) Chapter 044. Abdominal Swelling and Ascites (Part 1) Harrisons Internal Medicine > Chapter 44. Abdominal Swelling andAscites Abdominal Swelling Abdominal swelling or distention is a common problem in clinicalmedicine and may be the initial manifestation of a systemic disease or ofotherwise unsuspected abdominal disease. Subjective abdominal enlargement,often described as a sensation of fullness or bloating, is usually transient and isoften related to a functional gastrointestinal disorder when it is not accompaniedby objective physical findings of increased abdominal girth or local swelling.Obesity and lumbar lordosis, which may be associated with prominence of theabdomen, may usually be distinguished from true increases in the volume of theperitoneal cavity by history and careful physical examination. Clinical History Abdominal swelling may first be noticed by the patient because of aprogressive increase in belt or clothing size, the appearance of abdominal oringuinal hernias, or the development of a localized swelling. Often, considerableabdominal enlargement has gone unnoticed for weeks or months, either because ofcoexistent obesity or because the ascites formation has been insidious, withoutpain or localizing symptoms. Progressive abdominal distention may be associatedwith a sensation of pulling or stretching of the flanks or groins and vague lowback pain. Localized pain usually results from involvement of an abdominal organ(e.g., a passively congested liver, large spleen, or colonic tumor). Pain isuncommon in cirrhosis with ascites, and when it is present, pancreatitis,hepatocellular carcinoma, or peritonitis should be considered. Tense ascites orabdominal tumors may produce increased intraabdominal pressure, resulting inindigestion and heartburn due to gastroesophageal reflux or dyspnea, abdominalwall hernias (inguinal and umbilical), orthopnea, and tachypnea from elevation ofthe diaphragm. A coexistent pleural effusion, more commonly on the right,presumably due to leakage of ascitic fluid through lymphatic channels in thediaphragm, may also contribute to respiratory embarrassment. A large pleuraleffusion, obscuring most of the lung, is known as a hepatic hydrothorax. Thepatient with diffuse abdominal swelling should be questioned about increasedalcohol intake, a prior episode of jaundice or hematuria, or a change in bowelhabits. Such historic information may provide the clues that will lead one tosuspect an occult cirrhosis, a colonic tumor with peritoneal seeding, congestiveheart failure, or nephrosis. Approach to the Patient: Abdominal Swelling A carefully executed general physical examination can yield valuable cluesconcerning the etiology of abdominal swelling. Thus palmar erythema and spiderangiomas suggest an underlying cirrhosis, while supraclavicular adenopathy(Virchows node) should raise the question of an underlying gastrointestinalmalignancy. Inspection of the abdomen is important. By noting the abdominal contour,one may be able to distinguish localized from generalized swelling. The tenselydistended abdomen with tightly stretched skin, bulging flanks, and evertedumbilicus is characteristic of ascites. A prominent abdominal venous pattern withthe direction of flow away from the umbilicus is often a reflection of portalhypertension; venous collaterals with flow from the lower part of the abdomentoward the umbilicus suggest obstruction of the inferior vena cava; flowdownward toward the umbilicus suggests superior vena cava obstruction.Doming of the abdomen with visible ridges from underlying intestinal loops isusually due to intestinal obstruction or distention. An epigastric mass, with evidentperistalsis proceeding from left to right, usually indicates underlying pyloricobstruction. A liver with metastatic deposits may be visible as a nodular rightupper quadrant mass moving with respiration. Auscultation may reveal the high-pitched, rushing sounds of early intestinalobstruction or a succussion sound due to increased fluid and gas in a dilatedhollow viscus. Careful auscultation over an enlarged liver occasionally reveals aharsh bruit signifying a vascular tumor (especially a hepatocellular carcinoma) oralcoholic hepatitis, or the leathery friction rub of a surface nodule. A venous humat the umbilicus may signify portal hypertension and an increased collateral bloodflow around the liver. A fluid wave and flank dullness that shifts with change inposition of the patient are important signs that indicate the presence of peritonealfluid, although a minimum of 1500 mL of fluid is usually required to producethese findings. In obese patients, small ...