ASCITES R MICHAEL RODRIGUEZ M D ASSOCIATE PROFESSOR

ASCITES R. MICHAEL RODRIGUEZ, M. D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

ASCITES DEFINITION – FREE FLUID IN THE ABDOMINAL CAVITY JAMA 1992; 267: 2645 -2648

PATHOPHYSIOLOGY OF ASCITES • HYDROSTATIC PRESSURE CIRRHOSIS CHF CONSTRICTIVE PERICARDITIS • OSMOTIC PRESSURE NEPHROTIC SYNDROME MALNUTRITION PROTEIN LOSING ENTEROPATHY • FLUID PRODUCTION EXCEEDING RESORPTIVE CAPACITY INFECTION – TB MALIGNANCY JAMA 1992; 267: 2645 -2648

HISTORY USEFUL • • • H/O INCREASED ABDOMINAL GIRTH H/O PEDAL EDEMA H/O WEIGHT GAIN H/O CHF H/O HEPATITIS NOT AS USEFUL • H/O ETOH • H/O MALIGNANCY JAMA 1992; 267: 2645 -2648

BULGING FLANKS ASCITES OR OBESITY? JAMA 1992; 267: 2645 -2648

SHIFTING DULLNESS METHOD OF EXAMINATION BEGIN BY PERCUSSING AT THE UMBILICUS AND MOVING TOWARD THE FLANKS. THE TRANSITION FROM AIR TO FLUID CAN BE IDENTIFIED WHEN THE PERCUSSION NOTE CHANGES FROM TYMPANIC TO DULL. ROLL THE PATIENT ON THEIR SIDE AND PERCUSS AS BEFORE. THE AREA OF TYMPANY WILL SHIFT TOWARDS THE TOP AND THE AREA OF DULLNESS TOWARDS THE BOTTOM. JAMA 1992; 267: 2645 -2648

SHIFTING DULLNESS PATIENT OR ASSISTANT TAP FEEL METHOD OF EXAMINATION HAVE THE PATIENT OR ASSISTANT PLACE THEIR HANDS IN THE MIDLINE TAP ONE FLANK SHARPLY AND USE THE FINGERTIPS OF THE OPPOSITE HAND TO FEEL FOR AN IMPULSE ON THE OPPOSITE FLANK JAMA 1992; 267: 2645 -2648

PUDDLE SIGN METHOD OF EXAMINATION PATIENT IS PRONE FOR 3 -5 MINUTES AND THEN RISES TO ALL FOURS DIAPHRAGM OF THE STETHOSCOPE IS PLACED OVER MOST DEPENDENT AREA OF THE ABDOMEN BEGIN BY FLICKING A FINGER OVER A LOCALIZED FLANK AREA MOVE THE STETHOSCOPE OVER THE OPPOSITE FLANK SUDDEN INCREASE IN INTENSITY IS A POSITIVE SIGN (NO LONGER USED) JAMA 1992; 267: 2645 -2648

SUMMARY • HISTORY • PERFORM APPROPRIATE EXAMINATION TO DIAGNOSE ASCITES • PUDDLE SIGN IS NO LONGER USED