Approach

• Expose patient
• Examine abdomen

1. Inspect
   • May be distended if gross asicities - distension will tend to be lateral as fluid accumulates in paracolic gutters
   • Begin with hands - peripheral stimata of liver disease
2. Palpate
3. Percuss
   • Flank dullness to percussion
   • Shifting dullness - define margin where percussion note first becomes dull in flank, then ask patient to roll towards yoou keeping finger on the same point on the abdomen, wait for fluid to resettle and then demonstrate percussion note has become resonant again
   • Fluid thrill - large volumes of ascities can transmitt a thrill - ask patient to place hand parallel to body over umbilicus, gently tap with hand and feel transmitted pulsation
4. Auscultate

Completion

1. Examine rest of abdomen
2. Check for sacral / ankle oedema (signs of hypoalbuminaemia)
3. Examine chest for signs of right heart failure

Causes of ascities:

1. Common
   • Chronic liver disease
   • Right heart failure
   • Intra-abdominal malignancy
   • Hypoalbuminaemia
2. Uncommon
   • Nephrotic syndrome
   • Tuberculosis
   • Chylous ascities

Performing ascitic tap

1. Sterile conditions +/- radiological guidance
2. LA and site marked
3. Narrow gauge needle introduced to check position
4. Large gauge cannula inserted into abdomen

Ascitic subtypes

Indications for use of shunt in management of ascities

1. Treat underlying condition
2. Weight reduction programme - with diuretics, low sodium diet
3. Diuretic-resistant ascities - shunting performed via a number of ways
   • Peritoneo-venous shunt (Le Veen shunt) - silastic catheter used to drain fluid into jugular vein
   • Denver shunt - small modification to Le Veen shunt adding subcutaneous pump that can be compressed externally

     

   • Transjugular intrahepatic portosystemic shunt (TIPS) - side to side shunt stenting a channel between a branch of the portal vein and hepatic vein