ASCITES
ASCITES: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the following questions:
- Is there associated dyspnea? If there is associated dyspnea, one should look for congestive heart failure, pulmonary emphysema, and other cardiopulmonary conditions.
- Is there hepatomegaly? If there is associated hepatomegaly, certainly cirrhosis of the liver has to top the list of possibilities, but additional causes of ascites with hepatomegaly are constrictive pericarditis, the cardiomyopathies, Budd-Chiari syndrome, metastatic carcinoma, and hydatid cyst.
- Is there edema of the lower extremities or significant proteinuria? Edema in the lower extremities along with significant proteinuria certainly suggests a nephrotic syndrome, whether it is due to glomerulonephritis, diabetes, or a collagen disease. It also suggests end-stage nephritis. If there is no significant proteinuria, then a primary peritoneal condition such as tuberculous peritonitis or peritoneal carcinomatosis must be considered. Remember, a large ovarian cyst can simulate ascites.
- Is there a history of a primary tumor elsewhere? GI tumors may spread to the peritoneal surface and cause ascites, but a malignant melanoma may do the same thing.
DIAGNOSTIC WORKUP
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.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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