Diagnostic Tests for Ascites
Ascites Tests: Book Excerpts
Ascites Diagnosis: Book Excerpts
Diagnostic Tests for Ascites: Online Medical Books
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ASCITES:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Ultrasonography may help confirm the presence of ascites and differentiate it from other conditions such as pregnancy or ovarian cysts. A peritoneal tap with analysis of the fluid to determine whether it is a transudate or exudate and cell block studies as well as amylase, culture and sensitivity should be done; an elevated amylase indicates pancreatic disease. A CBC, chemistry panel, urinalysis, and sedimentation rate need to be done in all cases, and the urinary sediment should be examined under the microscope.
To rule out congestive heart failure, venous pressure and circulation time, EKG, pulmonary function studies, echocardiography, and chest x-ray should be done. To rule out pulmonary emphysema, pulmonary function studies and chest x-rays should be done. To rule out liver disease, a liver profile may be done along with a serum protein electrophoresis and a CT scan of the liver. A tuberculin test can be done to rule out tuberculous peritonitis, but the ascitic fluids should be studied with an
AFB
smear and culture. Guinea pig inoculation is sometimes necessary for a positive diagnosis. Laparoscopy is useful in differentiating peritoneal carcinomatosis from tuberculous peritonitis. A CT scan of the abdomen should be done to determine if there is peritoneal carcinomatosis or a primary malignancy of the GI tract and other structures in the abdomen. An upper GI series and barium enema may need to be done. Also, colonoscopy and gastroscopy may need to be done.
As the diagnostic tests become more expensive, the clinician should consider a referral to a gastroenterologist, nephrologist, or hepatologist before proceeding.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.)
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Ascites:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Diagnostic paracentesis should be performed to determine the nature of the ascitic fluid and to evaluate for the presence of SBP.
B. An ascitic fluid polymorphonuclear leukocyte count of more than 250 cells/mm3 indicates infection (SBP) and the patient should be empirically treated as such.
C. If a culture is obtained, 10 ml of ascitic fluid should be injected into blood culture bottles at the bedside to increase sensitivity (1,4).
D. The serum-ascites albumin gradient (SAAG) is the difference between the serum albumin concentration and the ascitic fluid albumin concentration. This gradient is 97% accurate in determining the underlying mechanism of ascites and replaces the former classification of ascitic fluid as either a transudate or an exudate (1). An SAAG of more than 1.1 g/dl indicates the patient has portal hypertension (seen with diagnoses such as cirrhosis, heart failure, alcoholic hepatitis, massive metastatic liver disease, or Budd-Chiari syndrome) (4). An SAAG of less than 1.1 g/dl indicates the patient does not have portal hypertension and a process such as peritoneal carcinomatosis, tuberculous peritonitis, pancreatic ascites, serositis from connective tissue diseases, nephrotic syndrome, or biliary ascites may be present (1,4).
E. Cytology, smear, and culture for mycobacteria are expensive and have very low yields. They should only be ordered if there is a very high pretest probability.
F. Other tests that can be ordered include amylase (pancreatic ascites), triglycerides (chylous ascites), and lactate dehydrogenase and glucose (secondary peritonitis) (4).
G. Ultrasonography can detect as little as 100 ml of fluid in the abdomen (3). It is useful both for confirming the presence of ascites and in guiding diagnostic paracentesis.
Diagnostic assessment
If ascites is suspected on history and physical examination, a diagnostic paracentesis should be performed. Basic orders include a cell count and differential and albumin concentration (ascitic and serum). The SAAG should be calculated. Culture and other optional tests should be performed, based on clinical suspicion. If the diagnosis is uncertain because of a low volume of ascites, an ultrasound should be performed to guide a diagnostic paracentesis. If the patient is having significant symptoms or tense ascites, a therapeutic large-volume paracentesis should be performed and the fluid analyzed as above. Complications of paracentesis have been reported in approximately 1% of patients (i.e., abdominal wall hematomas), including those with an underlying coagulopathy (1).
A. Indications for hospitalization (5) or referral include:
1. Worsening ascites despite initial management attempts
2. Tense ascites
3. Systemic signs or symptoms (liver failure, renal failure, encephalopathy, pancreatitis, gastrointestinal bleeding)
4. Suspicion of infection (SBP)
5. Patient noncompliant with medical management
References
1. Runyon BA. Management of adult patients with ascites caused by cirrhosis. AASLD practice guidelines. Hepatology 1998;27(1):264–272.
2. Cattau EL, Benjamin SB, Knuff TE, Castell DO. The accuracy of the physical examination in the diagnosis of suspected ascites. JAMA 1982;247:1164.
3. Goldberg BB, Goodman GA, Clearfield HR. Evaluation of ascites by ultrasound. Radiology 1970;96:15–22.
4. Habeeb KS, Herrera JL. Management of ascites. Paracentesis as a guide. Postgrad Med 1997;101(1):191–200.
5. Lipsky MS, Sternbach MR. Evaluation and initial management of patients with ascites. Am Fam Physician 1996;54(4):1327–1333.>>>
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Abdominal/Pelvic Mass:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Abdominal distention:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a complete physical examination. Don’t restrict the examination to the patient’s abdomen because you could miss important clues to the cause of his abdominal distention. 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 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, and 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 abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Abdominal mass:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
A complete physical assessment should be performed. Be sure to 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. (See Performing an abdominal assessment.)
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.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Abdominal Masses:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Age of child,location and characteristics of mass, and associated clinical findingsare important factors in diagnosis.Liver masses are in right upper quadrant,splenic masses in left upper quadrant, and kidney masses in flanks;masses involving intestine and ovaries are likely to be palpablein lower quadrants.Any solid mass should be consideredmalignant until proved otherwise.If diagnosis is uncertain after historyand physical exam, abdominal radiographs should be performed.Most useful single test is abdominalU/S, which usually locates involved organ of origin and whethermass is solid or cystic, renal or extrarenal.CT and MRI play important role by demonstratinganatomic features of mass as well as local and metastatic extentof malignant lesions.Chest radiograph may be useful, especiallywith suspected neoplastic lesions. Renal Masses
Responsiblefor >50% of palpable abdominal masses in neonates.If mass is intrarenal, cystic, andsolitary, it is usually benign renal cyst. If it is cystic and multiloculated,renal multicystic dysplasia is usual diagnosis.In infants <1 yr, solid renalmasses are either congenital mesoblastic nephroma or Wilms tumor.These 2 tumors are indistinguishable by imaging exam.In children >1 yr, nearlyall solid intrarenal masses are Wilms tumors. Gastrointestinal Masses
Plain abdominalradiography and abdominal U/S are most important initialstudies.Other studies depend on suspected diagnosis:air-contrast enema (intussusception), CT (intestinal duplication,abscess, neoplasm), and upper GI series (volvulus). Liver Masses
Cystic lesionsare usually benign cysts, whereas solid intrahepatic lesions usuallysignify tumor. In latter case, CT and/or MRI help definelocation and extent of the mass.Histologic diagnosis is confirmatory. Splenic Masses
May be diagnosedby abdominal U/S.Malignant disease usually is infiltrativein nature (leukemia) and causes splenomegaly rather than discretesplenic mass. Involvement of the spleen by lymphoma may be infiltrativeor with discrete tumor foci. Biliary Tract Masses
Most arecystic and benign (choledochal cyst, hydrops of gallbladder) inchildren.Can usually be diagnosed by abdominalU/S. Adrenal Masses
Abdominal U/S can distinguish adrenalhematoma from neuroblastoma. Imaging cannot distinguish betweenneuroblastoma, ganglioneuroma, or ganglioneuroblastoma, and histologicdiagnosis is mandatory.
Genital Tract Masses
Usuallyovarian cysts in infant girls.May be readily diagnosed by abdominalU/S.Most common pelvic tumors in girlsare ovarian tumors. Further imaging is needed with CT or MRI.With pelvic mass in postmenstrual female,pregnancy test and U/S should be performed.If mass appears to be small functionalfollicular cyst, individual should be observed for 2–3mos to see whether it regresses.If it is >5 cm in diameterat time of diagnosis or suspicion of malignancy exists, laparoscopy orlaparotomy should be performed to make definitive histologic diagnosis. Pancreatic Masses
Most arepseudocysts and require no further imaging other than abdominalU/S.Rarely, solid pancreatic tumors occurand are either carcinomas or endocrine tumors. >
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Abdominal distention:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
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.
The patient may be unable to bend at the 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.) When did the patient last have a bowel movement? 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 and pregnancy. Inspect the abdomen for signs of inguinal or femoral hernia and for healed incisions that may point to adhesions. Both may lead to intestinal obstruction. 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. 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.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Abdominal mass:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
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 the first day of her last menses.
A complete physical examination should be performed. Inspect the abdomen for asymmetry, scarring, discoloration, or other skin abnormalities. Also observe for pulsations. 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? 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, page 8.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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