Page 192 - Medicine and Surgery

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188 Chapter 5: Hepatic, biliary and pancreatic systems

Gynaecomastia, which may be due to increased oe- Table 5.1 Causes of ascites

strogen levels or drugs such as spironalactone. Loss of
Transudate Exudate
axillary hair is another sign.
Tattoosmayindicateapossiblesourceofprevioushep-
Hypoalbuminaemia (e.g. Malignancy
nephrotic syndrome) Chylous ascites
atitis infection.
Raised central venous Hepatic vein obstruction
Slate-grey pigmentation of the skin occurs in pressure (Budd–Chiari syndrome)

haemochromatosis. Chronic liver disease Pancreatitis
There may be a hepatic flap, which is a flapping tremor
Portal vein obstruction Inflammatory bowel disease
of the outstretched hands. Congestive cardiac failure
The abdomen and lower limbs:
Hepatomegaly and/or splenomegaly (see page 463).

is common but severe pain is more likely to result from
Ascites (see page below).

the underlying cause.
Caput medusa (see below).

Testicular atrophy in males.

Investigations
Ankle oedema (due to right heart failure or hypoal-

The diagnosis can be confirmed by ultrasonography. A
buminaemia).
diagnostic aspiration of the fluid should be obtained. A
In early cirrhosis liver function is adequate, so that pa-
transudate is suggested by a protein of ≥11 g/L below
tients are asymptomatic and do not have complications.
the serum albumin level.
In more severe disease portal hypertension, low serum
Clear fluid is seen in liver disease and hypoalbu-
albumin and other complications occur. This is called
minaemia. Bloodstained fluid suggests malignancy.
decompensated cirrhosis. Patients may fluctuate back
Milky fluid suggests chylous ascites.
and forth, depending on intercurrent events such as in-
Very high protein counts are found in tuberculous
fections.
ascites,pancreaticascitesandBudd–Chiarisyndrome.
Signsofdecompensated cirrhosis:
Ascitic fluid amylase is raised in pancreatic ascites.
Deep jaundice.

Fluidissentformicroscopy,Gramstainandculture(in
Ascites, with or without peripheral oedema.

bloodculturebottles).Morethan250whitebloodcells
Hepatic encephalopathy, i.e. any drowsiness, confu-

per millilitre indicates infection (subacute bacterial
sion, hepatic flap and hepatic fetor.
peritonitis).
Development of dilated collateral veins, i.e. veins

Fluid should also be sent for cytology.
around the umbilicus (caput medusa, which are very
rare) or oesophageal varices, which can lead to upper
gastrointestinal haemorrhage. Management
Treatment depends on the underlying cause. The
progress of ascites can be monitored using repeated
Ascites weight and girth measurements. Sodium intake should
be restricted but protein and calorie intake should be
Definition
maintained. Water restriction is only necessary if the
Ascites is the accumulation of fluid within the peritoneal
serum sodium concentration drops below 128 mmol/L.
cavity.
The combination of spironolactone and furosemide is
effective in the majority of patients. Patients who not
Aetiology/pathophysiology respond to this treatment may require
Ascites may be a transudate or an exudate dependent on therapeutic paracentesis, the removal of fluid over a
the protein content (see Table 5.1). number of hours. If more than1Lof fluid is removed
then intravenous albumin or plasma expander is re-
Clinical features quired to prevent hypovolaemia.
Ascites presents as abdominal distension with shifting refractory ascites may be treated by TIPPS (see page
dullness and a fluid thrill on examination. Discomfort 199).