Chapter 044. Abdominal Swelling and Ascites (Part 2)

Palpation is often difficult with massive ascites, and ballottement of overlying fluid may be the only method of palpating the liver or spleen. A slightly enlarged spleen in association with ascites may be the only evidence of an occult cirrhosis. When there is evidence of portal hypertension, a soft liver suggests that obstruction to portal flow is extrahepatic; a firm liver suggests cirrhosis as the likely cause of the portal hypertension. A very hard or nodular liver is a clue that the liver is infiltrated with tumor, and when accompanied by ascites, it suggests that the latter is due...
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Chapter 044. Abdominal Swelling and Ascites (Part 2) Chapter 044. Abdominal Swelling and Ascites (Part 2) Palpation is often difficult with massive ascites, and ballottement ofoverlying fluid may be the only method of palpating the liver or spleen. A slightlyenlarged spleen in association with ascites may be the only evidence of an occultcirrhosis. When there is evidence of portal hypertension, a soft liver suggests thatobstruction to portal flow is extrahepatic; a firm liver suggests cirrhosis as thelikely cause of the portal hypertension. A very hard or nodular liver is a clue thatthe liver is infiltrated with tumor, and when accompanied by ascites, it suggeststhat the latter is due to peritoneal seeding. The presence of a hard periumbilicalnodule (Sister Mary Josephs nodule) suggests metastatic disease from a pelvic orgastrointestinal primary tumor. A pulsatile liver and ascites may be found intricuspid insufficiency. An attempt should be made to determine whether a mass is solid or cystic,smooth or irregular, and whether it moves with respiration. The liver, spleen, andgallbladder should descend with respiration unless they are fixed by adhesions orextension of tumor beyond the organ. A fixed mass not descending withrespiration may indicate that it is retroperitoneal. Tenderness, especially iflocalized, may indicate an inflammatory process such as an abscess; it also may bedue to stretching of the visceral peritoneum or tumor necrosis. Rectal and pelvicexaminations are mandatory; they may reveal otherwise undetected masses due totumor or infection. Radiographic and laboratory examinations are essential for confirming orextending the impressions gained on physical examination. Upright and recumbentfilms of the abdomen may demonstrate the dilated loops of intestine with fluidlevels characteristic of intestinal obstruction or the diffuse abdominal haziness andloss of psoas margins suggestive of ascites. Ultrasonography is often of value indetecting ascites, determining the presence of a mass, or evaluating the size of theliver and spleen. CT scanning provides similar information and is often necessaryto visualize the retroperitoneum, pancreas, and lymph nodes. A plain film of theabdomen may reveal the distended colon of otherwise unsuspected ulcerativecolitis and give valuable information as to the size of the liver and spleen. Anirregular and elevated right side of the diaphragm may be a clue to a liver abscessor hepatocellular carcinoma. Studies of the gastrointestinal tract with barium orother contrast media are usually necessary in the search for a primary tumor. Laboratory abnormalities that are highly suggestive of cirrhosis as the causeof ascites include unexplained thrombocytopenia, decreased albumin, and aprolonged prothrombin time. Ascites The evaluation of a patient with ascites requires that the cause of the ascitesbe established. In most cases ascites appears as part of a well-recognized illness,i.e., cirrhosis, congestive heart failure, nephrosis, or disseminated carcinomatosis.In these situations, the physician should determine that the development of ascitesis indeed a consequence of the basic underlying disease and not due to thepresence of a separate or related disease process. This distinction is necessary evenwhen the cause of ascites seems obvious. For example, when the patient withcompensated cirrhosis and minimal ascites develops progressive ascites that isincreasingly difficult to control with sodium restriction or diuretics, the temptationis to attribute the worsening of the clinical picture to progressive liver disease.However, an occult hepatocellular carcinoma, portal vein thrombosis, spontaneousbacterial peritonitis, alcoholic hepatitis, viral infection, or even tuberculosis maybe responsible for the decompensation. The disappointingly low success indiagnosing tuberculous peritonitis or hepatocullar carcinoma in the patient withcirrhosis and ascites reflects the too-low index of suspicion for the development ofsuch superimposed conditions. Similarly, the patient with congestive heart failuremay develop ascites from a disseminated carcinoma with peritoneal seeding. It isimportant to note, however, that while there are many different causes of ascites,in the United States >80% of cases are due to cirrhosis. Risk factors for thedevelopment of cirrhosis include alcoholism, viral hepatitis, nonalcoholicsteatohepatitis, and a family history of liver disease. Diagnostic paracentesis (50–100 mL) should be part of the routineevaluation of the patient with ascites, and does not routinely require the prioradministration of platelets or fresh-frozen plasma unless disseminatedintravascular coag ...