Ascites and abdominal swelling

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Ascites and abdominal swelling

• Int jeerawat silasuwan MD

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Clincal history

• progressive increase in belt or clothing size
• insidious onset , without pain
• coexistent obesity
• flank , groins, low back pain
• localized pain congestived liver, large
  spleen, or colonic tumor
• Pain is uncommon in cirrhosis except
  pancreatitis, HCC,peritonitis

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Clincal history

• Increase intra-abdominal pressure ? GERD,
  dyspnea, orthopnea, tachypnea
• Hepatic hydrothorax ? leakage through lymphatic
  chanels

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Physical examination

• Inspection
• Ascites tensely abdomen,tightly stretched skin
  , bulging flanks, everted umbilicus
• Venuos pattern
• obstruction IVC flow lower part to umbilicus
  
• - obstruction SVC flow upper part to umbilicus
  

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Physical examination

• Auscultation
• High pitched,rushing sound ? gut obstruction
• Succussion sound ?increase fluid in hallow
  viscus
• Harsh bruit at liver ?HCC or vascular
  tumor,friction rub ? liver metastasis
• Venous hum at umbilicus ?portal HT

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Physical examination

• Percussion
• Generalized abdominal swelling, careful localized
  swelling ?uterus mass,ovarian cyst,ditended
  bladder
• Shifting dullness

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Shifting dullness
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Physical examination

• Palpation
• Sister Mary Joseph nodule

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Radiographic examinations
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condition grass protein SAAG RBC gt1000 WBC other
cirrhosis Straw,bile lt25 gt1.1 1 lt250
neoplasm Straw,blood,mucus, chylous gt25 lt1.1 20 gt1000 cyto
TB Clear,turbid,bloody, chylous gt25 lt1.1 7 gt1000 Lgt70 AFB
Pyogenic peritonitis Turbid,pus gt25 lt1.1 rare PMN gram
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condition grass protein SAAG RBC gt1000 WBC other
CHF Straw 15-53 gt1.1 10 lt1000 Mesothium,mono
nephrosis Straw, chylous lt25 lt1.1 rare lt250 sudan
Pancreatitic ascites Turbid , Bloody, chylous variable gt25 lt1.1 Variable May be bloody variable amylase
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Chylous ascites

• Turbid,milky,creamy
• Sudan staining fat globule
• Increase TG gt1000 mg/dL
• Pseudochylous ? WBC, tumor
• Test ? alkali ?lysis cell
• Lymphatic obstruction-gt trauma,tumor,TB,filariasis
  ,nephrotic syndrome

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Mucinous ascites

• Pseudomyxoma peritonei
• Rare colliod CA

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SAAG

• SAAG gt 1.1 mg/dl
• Cirrhosis
• Alcoholic Hepatitis
• Cardiac Ascites
• Massive Liver Metastasis
• Fulminant Hepatic Failure
• Budd-Chiari Syndrome
• Portal Vein Thrombosis
• Veno-Occlusive Disease
• Myxedema
• Fatty Liver of Pregnancy

• SAAG lt 1.1 mg/d
• Peritoneal Carcinomatosis
• Tuberculous Peritonitis
• Pancreatic Ascites
• Bowel Obstruction
• Biliary Ascites
• Posteroperative Lymphatic Leak
• Serositis in Connective Tissue Disease
• nephrosis

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the end