The space between visceral and parietal peritoneum (peritoneal cavity) contains a few millimeters of fluid which communicates freely with blood because of absorption by peritoneal cells. This fluid in excess amount is termed as ascites.
Causes of Ascites
- Liver diseases – chronic hepatitis, cirrhosis, sub – acute hepatic failure and Budd – chiari syndrome.
- Cardiac diseases – congestive heart failure, constrictive pericarditis, pericardial effusion and valvular heart disease.
- Renal diseases – nephrotic syndrome, nephrogenic ascites and chronic dialysis.
- Pancreatic diseases – acute and chronic pancreatitis and traumatic pancreatic disruption.
- Miscellaneous causes – protein losing enteropathy and myxedema.
- Peritoneal infections – surgical peritonitis, spontaneous bacterial peritonitis, tuberculosis and amoebiasis.
- Malignant diseases – peritoneal carcinomatosis, metastatic liver disease and hepatocellular cancer.
Clinical assessment and Clinical history check for Ascites –
- Risk factors for liver disease should be obtained e.g. blood transfusion, intravenous (IV) drug abuse, and alcoholism.
- Past history of cancer (breast, lung and colon).
- Painless ascites favors portal hypertension while abdominal pain suggests primary peritoneal disease.
- Common causes of ascites are cirrhosis and peritoneal tuberculosis.
- Clinical examination-
- Physical examination reveals generalized fluid collection (anasarca) – seen in nephrotic syndrome and heart failure.
- In cirrhosis, edema is limited to dependent areas (legs, back).
- Engorged neck veins indicate heart failure or constrictive pericarditis.
- Presence of spider naevi and palmar erythema suggests liver disease.
- Abdominal examination –
- It shows fullness in flanks. In portal hypertension, abdominal veins fan out from umbilicus. In inferior vena cava block dilated veins are seen on flanks and back.
- Umbilical and inguinal hernias are common in patients with large ascites.
- An umbilical nodule suggests peritoneal carcinomatosis.
- Ascites fluid analysis –
- A diagnostic tap is done using a 22 – gauge hypodermic needle.
- Site of tapping –
- The midline infra – umbilical site is safest because it is avascular. The lowest quadrants, two finger – breaths superior and medial to anterior superior iliac spine are most convenient. If fluid amount is small, patient is rolled on one side in knee elbow position and needle is inserted in most dependent site. In case of loculated fluid a USG guided tapping is done.
- Normal ascitic fluid is clear, slightly yellow. Increased WBC in fluid indicates infection or malignancy. Increased neutrophils are seen in bacterial peritonitis. Lymphocytes are increased in tuberculosis.
- If total protein content of fluid is less than 2.5q/dl – it is termed as transudate (seen in heart failure and cirrhosis).
- If protein content is more than 2.5q/dl – it is termed as exudate (seen in peritoneal diseases, infections and malignancy).
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