Ascites - Diagnostic Approach and Differential Diagnosis
The most common causes: cirrhosis, malignancy and heart failure. Approx 5% of patients w/ ascites have more than one cause (e.g. cirrhosis + TB, peritonitis, peritoneal carcinomatosis, HF, etc.).
1) Most relevant findings: Fluid wave (LR 5.3), peripheral edema (LR 3.8) / absence of edema (LR 0.17), shifting dullness (LR 2.1) - fluid wave/shifting dullness detect > 1 litre of ascites.
2) Other findings: bulging flanks, flank dullness, puddle sign, auscultatory percussion, abdominal wall hernias (umbilical, inguinal, incisional).
3) Signs of underlying disease: Cirrhosis, Malignancy, Heart Failure
Labs + Ascitic Fluid Analysis:
1) General appearance: Uncomplicated ascites: clear, pale straw-colored yellow, infection: hazy, cloudy or bloody fluid; hemorrhagic: frank blood; chylous: milky fluid; brown: elevated bilirubin
2) Routine tests: Cell count and differential, albumin and total protein concentration
3) Optional tests: Culture in blood culture bottles (infection, bowel perforation), glucose concentration (malignancy, infection, bowel perforation), LDH (malignancy, infection, bowel perforation), gram stain (suspected bowel perforation), amylase concentration (pancreatic ascites or bowel perforation), TB smear/culture/ADA (TB peritonitis), cytology/CEA antigen (malignancy), triglyceride (chylous ascites), bilirubin
concentration (bowel or biliary perforation), Serum pro-brain natriuretic peptide (heart failure)
Dr. Jorge Cortés @Jcortesizaguirr
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