Diagnosis of Ascites

• Bile ascites (bile peritonitis): Spontaneous rupture of the common bile duct
• Renal
  –Nephrotic syndrome
  –Urinary ascites (due to bladder rupture)
  –Obstructive uropathy: Congenital ascites may be seen with bilateral hydronephrosis
• Peritoneal dialysis
• Cardiac
  –Congestive heart failure
  –Chronic constrictive pericarditis
  –Inferior vena cava web
  –Erythroblastosis fetalis
• Peritonitis
  –Tuberculous peritonitis
  –Schistosomiasis (Mansoni)
  –Tularemia
  –Abscess
• Gastrointestinal disorders
  –Infarcted bowel
  –Bowel perforation
  –Pancreatitis, ruptured pancreatic duct
  –Protein-losing gastroenteropathy
• Chylous ascites
  –Collection of lymph within the abdominal cavity; secondary to lymphatic obstruction from trauma, surgery, tumor, tuberculosis, or filariasis
• Gynecologic
  –Ovarian tumors, cyst torsion or rupture
• Malignancy
  –Leukemia, lymphoma, neuroblastoma
• Systemic lupus erythromatosus
• Ventriculoperitoneal shunt
• Hypothyroidism

Workup and Diagnosis

• History and physical exam
  –Clinical hallmark of ascites is abdominal distension
  –Five classic signs of ascites: Flank bulging, flank dullness, shifting dullness, fluid wave, puddle sign
  –Only appreciated when there is considerable fluid
  –Respiratory distress may develop with tense ascites
  –Umbilical herniation can be seen with large ascites
  –Peripheral edema or anasarca may accompany severe hypoalbuminemia

• Urinalysis and urine electrolytes (for proteinuria)
• CBC with diff (lymphopenia in lymphatic obstruction)
  
• Serum electrolytes (for sodium management)
• True liver function tests
  –Examines the synthetic function of the liver
  –Serum albumin, vitamin K, and coagulation factors
• Abdominal ultrasound detects small volume of ascites
  
• KUB may show centrally floating intestines

• Paracentesis: Milky fluid indicates chylous ascites, fluid analysis will reveal elevated protein and triglycerides and lymphocytosis (fluid serous in a fasting patient)
  –Bile may indicate perforation of common bile duct
  –High creatinine: Seen with bladder rupture
  –Ascitic fluid analysis for cell count, cytology, protein, LDH, amylase, lipase, creatinine, pH, culture, Gram stain, bile, lipids, and sudan red staining for fat

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Wilms tumor
  –More common in younger children
• Neuroblastoma
  –More common in younger children
• Leukemia/lymphoma
  –Involvement of retroperitoneal nodes, liver, or spleen
• Hepatic tumors
  –Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease
• Germ cell tumors
  –Ovarian, teratoma
• Soft tissue sarcoma
  –Rhabdomyosarcoma
• Rare malignancies in children
  –Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor
• Cystic masses
  –Ovary, renal, mesenteric
• Benign tumors
  –Adenomas (especially of liver), hamartomas, pheochromocytoma
• Vascular lesions (e.g., hemangioma)
• Renal etiologies
  –Distended, nonemptying bladder, bladder outlet obstruction
  –Congenital mesoblastic nephroma
  –Severe hydronephrosis
• Gynecologic
  –Ovarian torsion, endometriosis, pelvic inflammatory disease
• Gastrointestinal
  –Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia
• Pancreatic pseudocyst
• Infectious
  –Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly
• Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine

Workup and Diagnosis

• History
  –Mass duration, growth rate, pain; fever, weight loss, bone pain, night sweats
  –Anorexia, vomiting, constipation or diarrhea, early satiety, jaundice; prematurity, umbilical catheterization; opsoclonus, myoclonus (neuroblastoma)
  –Vaginal bleeding/amenorrhea, sexual activity, previous pregnancies/fertility, history of STDs; urinary dysfunction, congenital urinary tract anomalies
  –Signs of catecholamine excess (sleeplessness, jitteriness, flushing, hypertension)

• Family history: Wilms tumor, neurofibromatosis, hepatic tumors, Beckwith-Wiedemann
• Physical exam: Vital signs, toxicity, pallor, puffiness; location, size, tenderness, consistency of mass; hemihypertrophy (with Wilms), lymph nodes; wheezing, rales, SVC syndrome; presence of ascites, visible venous dilation; testicular exam, rectal; pelvic examination in teenagers; petechiae, purpura/ecchymoses, café au lait spots
• Labs: CBC with differential; electrolytes, BUN, Cr, LFT albumin, urinalysis; LDH, uric acid, PT/PTT/INR, ferritin, viral titers (EBV, CMV, hepatitis), tumor markers, stool guaiac
• Studies: KUB/upright film, chest X-ray; CT of chest/abdomen/pelvis; abdominal ultrasound; bone marrow aspirate/biopsy

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Source: In A Page: Pediatric Signs and Symptoms, 2007

ABDOMINAL MASS, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.

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Source: Differential Diagnosis in Primary Care, 2007

Abdominal distention: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat. (See Abdominal distention: Common causes and associated findings.)

The patient may also feel unable to bend at his waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites, page 4.) Also, note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, such as falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obesity. Inspect the abdomen for signs of inguinal or femoral hernia and for incisions that may point to adhesions. Both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash — a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. However, an abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient’s abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal mass: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menstrual period was.

A complete physical examination should be performed. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes.)

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal distention: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal mass: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, take a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in its size or location.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the 1st day of her last menstrual period was.

Perform a complete physical examination. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.

Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.

Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and causes, page 10.)  

After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Ascites: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Does the patient use alcohol or drugs? Alcoholic hepatitis is the most common cause of cirrhosis and ascites. Intravenous drug use places the patient at risk for ascites from either acute or chronic viral hepatitis (hepatitis B and C).

 B. Is the patient at risk for sexually transmitted diseases? Hepatitis B is commonly acquired sexually, therefore a complete sexual history is mandatory.

 C. Is the patient otherwise at risk for acquiring hepatitis? Other individuals at risk include hemodialysis patients, recipients of organ transplantations, close contacts of persons with hepatitis, members of high-risk populations (Asia, the South Pacific, sub-Saharan Africa), recipients of blood or blood products, individuals with tattoos, prior acupuncture or ear piercing, and needlestick victims.

 D. Does the patient have signs of fluid retention? Ask about increased abdominal girth, weight gain, leg edema, penile or scrotal edema, and umbilical herniation (Chapter 2.3).

 E. Are there any secondary symptoms to suggest fluid retention? Increased abdominal fluid leads to vague complaints of nausea, anorexia, early satiety, heartburn, abdominal pain, shortness of breath, or orthopnea.

F. Is there a suspicion of infection? Of patients admitted with ascites, 10% to 27% have spontaneous bacterial peritonitis (SBP); 48% to 57% of these patients will die (4). Ask about fever, abdominal pain, or mental status changes (encephalopathy) (Chapters 2.6, 3.2, and 9.1).

G. Is there a past history of heart failure, cancer, or tuberculosis? These are included in the 20% of nonhepatic causes of ascites.

Physical examination

Obtain vital signs (temperature, respiratory rate, blood pressure, and weight). Ascites is rarely the sole physical finding. Examine for evidence of liver disease (jaundice, spider angiomata, Dupuytren’s contracture, caput medusae); hepatomegaly may be absent if chronic cirrhosis exists. Examine the skin for evidence of intravenous (IV) drug use, tattoos, and pigment changes (hemochromatosis). Jugular venous distention, a third heart sound, pulmonary crackles, and peripheral edema suggest heart failure. Abdominal tenderness can reflect pancreatitis or infection. Tests for ascites include shifting dullness, bulging flanks, flank dullness, fluid wave, and the “puddle” sign (i.e., percussing the abdomen with the patient on hands and knees). The reliability of these tests are unpredictable (2). These techniques are not helpful when a small volume ( <1,000 ml) of ascites exists; 1,500 ml of fluid must be present before shifting dullness is detected. The “puddle” sign is no longer considered valuable because of its low sensitivity and patient discomfort (2,5).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

Diagnostic Approach

Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.

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Source: Field Guide to Bedside Diagnosis, 2007

Peritonitis: Diagnosis
(Handbook of Diseases)

Severe abdominal pain in a patient with direct or rebound tenderness suggests peritonitis. Abdominal computed tomography scan or X-rays showing edematous and gaseous distention of the small and large bowel support the diagnosis. In the case of perforation of a visceral organ, the X-ray shows air in the abdominal cavity.

Other tests include the following:

❑ Chest X-ray may show elevation of the diaphragm.

❑ Blood studies reveal leukocytosis (greater than 20,000/µl).

❑ Paracentesis reveals bacteria, exudate, blood, pus, or urine.

❑ Laparotomy may be necessary to identify the underlying cause.

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Source: Handbook of Diseases, 2003

Abdominal distention: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing when lying flat or breathing deeply. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, and inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal mass: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.

Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menses was.

CULTURAL CUE:When taking a health history, consider your patient’s ethnic background. For example, Japanese patients are at higher risk for gastric cancer than non-Japanese patients and cirrhosis tends to be more common in Native American patients than in patients of other ethnic backgrounds.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal Masses: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Right Upper Quadrant

Liver

Hepatomegaly