Ascites Clinical Presentation

  • Author: Rahil Shah, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 4, 2012
 

History

  • Patients with ascites often state that they have recently noticed an increase in their abdominal girth.
  • Because most cases of ascites are due to liver disease, patients with ascites should be asked about risk factors for liver disease. These include the following:
  • Patients with alcoholic liver disease who alternate between heavy alcohol consumption and abstention (or light consumption) may experience ascites in a cyclic fashion.
  • When a patient with a very long history of stable cirrhosis develops ascites, the possibility of superimposed hepatocellular carcinoma (HCC) should be considered.
  • Obesity, hypercholesterolemia, and type 2 diabetes mellitus are recognized causes of nonalcoholic steatohepatitis, which can progress to cirrhosis.
  • Patients with a history of cancer, especially gastrointestinal cancer, are at risk for malignant ascites. Malignancy-related ascites is frequently painful, whereas cirrhotic ascites is usually painless.
  • Patients who develop ascites in the setting of established diabetes or nephrotic syndrome may have nephrotic ascites.
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Physical

The physical examination in a patient with ascites should focus on the signs of portal hypertension and chronic liver disease.

  • Physical findings suggestive of liver disease include jaundice, palmar erythema, and spider angiomas.
  • The liver may be difficult to palpate if a large amount of ascites is present, but if palpable, the liver is often found to be enlarged. The puddle sign may be present when as little as 120 mL of fluid is present. When peritoneal fluid exceeds 500 mL, ascites may be demonstrated by the presence of shifting dullness or bulging flanks. A fluid-wave sign is notoriously inaccurate.
  • Elevated jugular venous pressure may suggest a cardiac origin of ascites. A firm nodule in the umbilicus, the so-called Sister Mary Joseph nodule, is not common but suggests peritoneal carcinomatosis originating from gastric, pancreatic, or hepatic primary malignancy.
  • A pathologic left-sided supraclavicular node (Virchow node) suggests the presence of upper abdominal malignancy.
  • Patients with cardiac disease or nephrotic syndrome may have anasarca.
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Causes

  • Normal peritoneum
    • Portal hypertension (serum-ascites albumin gradient [SAAG] >1.1 g/dL)
      • Hepatic congestion, congestive heart failure, constrictive pericarditis, tricuspid insufficiency, Budd-Chiari syndrome
      • Liver disease, cirrhosis, alcoholic hepatitis, fulminant hepatic failure, massive hepatic metastases
    • Hypoalbuminemia (SAAG < 1.1 g/dL)
      • Nephrotic syndrome
      • Protein-losing enteropathy
      • Severe malnutrition with anasarca
    • Miscellaneous conditions (SAAG < 1.1 g/dL)
      • Chylous ascites
      • Pancreatic ascites
      • Bile ascites
      • Nephrogenic ascites
      • Urine ascites
      • Ovarian disease
  • Diseased peritoneum (SAAG < 1.1 g/dL)
    • Infections
      • Bacterial peritonitis
      • Tuberculous peritonitis
      • Fungal peritonitis
      • Human immunodeficiency virus (HIV)-associated peritonitis
    • Malignant conditions
      • Peritoneal carcinomatosis
      • Primary mesothelioma
      • Pseudomyxoma peritonei
      • Hepatocellular carcinoma
    • Other rare conditions
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Contributor Information and Disclosures
Author

Rahil Shah, MD  Consulting Staff, Lebanon Endoscopy Center

Rahil Shah, MD is a member of the following medical societies: American College of Gastroenterology and American Society for Gastrointestinal Endoscopy

Disclosure: Takeda Consulting fee Speaking and teaching

Coauthor(s)

Janice M Fields, MD  Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, William Beaumont Hospital, St. John Macomb-Oakland Hospital

Janice M Fields, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and National Medical Association

Disclosure: Salic Pharmaceuticals Honoraria Review panel membership

Specialty Editor Board

Robert J Fingerote, MD, MSc, FRCPC  Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James L Achord, MD  Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine

James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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This computed tomography scan demonstrates free intraperitoneal fluid due to urinary ascites.
Peritoneovenous shunt.
Massive Acites
 
 
 
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