Ascites

Relevant physical signs

• Stigmata of chronic liver disease
  • Clubbing
  • Leukonychia
  • Palmar erythema
  • Spider naevi
  • Gynaecomastia
  • Loss of axillary hair
  • Hepatomegaly (tender suggests Budd-Chiari syndrome / acute viral hepatitis)
• Decompensated liver disease
  • Asterixis
  • Icterus
  • Ascites
• Portal hypertension
  • Distended abdominal veins
  • Splenomegaly
• Underlying malignancy
  • Palpable masses
  • Palpable lymphadenopathy
• Underlying diabetes (and hence diabetic nephropathy)
  • Diabetic dermopathy
  • Finger prick marks for blood sugar monitoring
  • Proprioceptive loss
• Underlying congestive cardiac failure
  • Raised jugular venous pressure
  • Peripheral oedema
  • Right ventricular heave / displaced apex beat
• Hypothyroidism
  • Coarse facial features
  • Hoarse voice
  • Goitre
  • Sinus bradycardia
  • Slow-relaxing reflexes
  • Macroglossia
• Signs of underlying autoimmune disease
  • Non-scarring alopecia
  • Oral ulcers
  • Malar rash / other vasculitic rash
  • Symmetrical deforming polyarthropathy (RA)

Differential diagnosis

• Chronic liver disease
  • Alcoholic liver disease
  • Non-alcoholic steatohepatitis
  • Viral hepatitis (chronic hepatitis B / C)
  • Inflammatory (primary biliary cirrhosis / primary sclerosing cholangitis / autoimmune hepatitis)
  • Metabolic (Wilson’s disease / haemochromatosis / alpha-1 antitrypsin deficiency)
• Neoplastic
  • Primary hepatocellular carcinoma
  • Ovarian carcinoma
  • Other intra-abdominal malignancies
  • Peritoneal carcinomatosis
• Other fluid overload states
  • Nephrotic syndrome
    • Diabetic nephropathy
    • Autoimmune membranous nephropathy (e.g. secondary to SLE)
    • Hepatitis B / C / HIV nephropathy
    • Paraneoplastic membranous nephropathy
  • Congestive cardiac failure
• Infection
  • Tuberculosis
  • Spontaneous bacterial peritonitis
  • Peritoneal dialysis peritonitis
• Vascular
  • Budd-Chiari syndrome (hepatic vein thrombosis)
  • Portal vein thrombosis
• Peritoneal dialysis fluid

Investigations

• Confirm diagnosis: abdominal ultrasound scan
  • Consider computed tomography of the abdomen and pelvis to look for aetiology
• Look for an underlying cause
  • Chronic liver disease
    • Tests of synthetic function of the liver: albumin, prothrombin time
    • Investigations for hepatocellular damage: liver function tests
    • Hepatitis B and C serology
    • Full blood count – thrombocytopaenia in hypersplenism
  • Nephrotic syndrome
    • Urine dipstick to screen for proteinuria
    • Urine protein:creatinine ratio or 24hr urine protein collection (>3g/day)
    • Fasting plasma glucose and HbA1c
    • Autoantibody screening, particularly anti-nuclear antibody
    • Test of renal function, as nephrotic syndrome is associated with progression to ESRF
  • Congestive cardiac failure
    • Transthoracic echocardiogram
    • Coronary angiogram to look for coronary artery disease if EF depressed
  • Malignancy / infection
    • Diagnostic paracentesis
      • Serum ascites – albumin gradient (SAAG): serum albumin – ascites albumin
        • Value < 11g/L suggests an exudate, >11 suggests a transudate
      • Fluid culture for bacteria and acid-fast bacilli
      • Fluid cytology to look for underlying malignancy
      • Fluid cell count to look for evidence of spontaneous bacterial peritonitis (PMN>250)
    • Consider age-appropriate malignancy screening and imaging to look for primary malignancy

Management

• Patient education: will recur unless underlying cause is corrected, salt and fluid restriction
• Diuretic therapy with spironolactone and / or furosemide
• Treatment of bacterial peritonitis with empirical, then directed, antibiotics
• Therapeutic paracentesis if ascites is tense

Summary

Sir, this patient has ascites with no evidence of underlying chronic liver disease. The ascites is tense and requires drainage. Differentials include nephrotic syndrome, congestive cardiac failure, a mitotic lesion or tuberculous peritonitis. To complete my examination, I would like to do a urine di, look at the temperature and assess the CVS.