Ascites Clinical Case Presentation,History Taking & Viva
Questions For Final Year MBBS
Examiner- Look at the patient & examine the patient ,what are your findings
- generalized distension of abdomen, flanks are full
- umbilicus is everted.
- Shifting dullness is present.
- Fluid thrill is present
Q: Why it is ascites?
A: Because there is shifting dullness (also fluid thrill, which is present in ascites).
Q: What are the causes of abdominal distension?
Others: intra-abdominal mass, retention of urine.
Q: What can be the causes of ascites ?
A: Tell the causes of that patient in relation to age, also sex:
• Cirrhosis of liver with portal hypertension (commonest cause, in 80% cases).
• Intra-abdominal malignancy with peritoneal metastasis (in elderly).
• Infection (tuberculous or pyogenic peritonitis).
• Others: Hypoproteinemia due to any cause, Meigs’ syndrome (in female)
Q: What is the single investigation to detect ascites?
Q: What is ascites? How much fluid is required to detect ascites clinically?
A: It is the pathological accumulation of free fluid in peritoneal cavity. Usually 2 L fluid is necessary to detect clinically (at least 1 L is necessary, even in thin person).
YOU MUST KNOW-Normally, no or little fluid is present in peritoneal cavity. In female, up to 20 mL may be present, varies with menstruation.
Q: If the patient has cirrhosis and ascites, what does it indicate?
A: Decompensated cirrhosis with portal hypertension (a bad prognostic sign).
Q: What is the character of ascitic fluid in CLD?
A: Usually clear, may be straw or light green and transudative.
Q: What investigations you will do in case of ascites?
A: As follows (according to suspicion of cause):
1. USG of abdomen (to see liver, spleen, para-aortic lymph nodes, neoplasm, ovary in female to exclude Meigs’ syndrome).
2. If CLD is suspected: LFT should be done (see in CLD).
3. CBC (high ESR in TB, leucocytosis in pyogenic infection. Pancytopenia with splenomegaly indicates hypersplenism).
4. Chest X-ray (to see TB,chronic constrictive pericarditis, May be pleural effusion).
5. Ascitic fluid aspiration
Q. Do you know about SAAG?
A: It is the difference of albumin between serum and ascitic fluid (calculated by serum albumin minus ascitic albumin).
It is the single test to differentiate ascites due to portal hypertension from non-portal hypertension.
• If the gradient is .1.1 g/dL, it indicates CLD with portal hypertension.
• If ,1.1, no portal hypertension (Indicates ascites due to non-portal hypertension. It is 97% accurate.)
YOU MUST KNOW- Ascites protein >25 g/L and SAAG >1.1 g/dL is usually suggestive of portal hypertension.
Q: What are the complications of ascites?
A: As follows:
• Hepatorenal syndrome.
• Mesenteric vein thrombosis.
YOU MUST KNOW-
Ascites may be exudative or transudative
1. Transudative causes (protein <25 g/L):
• Cirrhosis of liver with portal hypertension.
• Nephrotic syndrome.
• Meigs’ syndrome.
2. Exudative causes (protein >25 g/L):
• Peritonitis (TB and pyogenic).
• Collagen disease.
Q: What is refractory ascites? What are the causes? How to treat?
A: Persistence of ascites despite maximum diuretic therapy (up to 400 mg spironolactone and 160 mg furosemide per day) with salt and water restriction, is called refractory ascites.
• Poor compliance.
• Severe hypoalbuminaemia.
• Infection (SBP).
• Development of HCC in cirrhosis or secondary causes like metastasis or TB.
Treatment: See the compliance, correction of albumin, paracentesis, TIPSS, LeVeen shunt, also treatment of primary cause.