Ascites is the accumulation of excess free fluid in the peritoneal cavity (Fig. 5). Patients with ascites can present with abdominal discomfort, increasing abdominal girth, weight gain and ankle or sacral swelling. The development of ascites is usually gradual, but sudden onset can result from acute decompensation of liver cirrhosis, malignancy, portal or splenic vein thrombosis and Budd–Chiari syndrome. Any history of malignancy in the abdomen or pelvis is relevant; however, abdominal metastasis can also result in ascites, especially from breast, ovarian, prostatic, testicular and haematological malignancies. Cirrhosis of the liver may result from alcoholism, previous hepatitis, Wilson’s disease, primary and secondary biliary cirrhosis and haemochromatosis. A previous history of TB should raise suspicion of secondary disease. Classical findings are shifting dullness and a fluid thrill. As liver disease and carcinomatosis account for 90% of the cases presenting with ascites, a detailed examination of all systems is required. The next commonest causes are cardiac failure and nephrotic syndrome. Evidence of liver disease would be suggested by the presence of jaundice, spider naevi, loss of body hair, gynaecomastia, palmar erythema and caput medusae. The jugular venous pressure (JVP) is elevated in the presence of cardiac failure, and a prominent ν wave is seen with tricuspid regurgitation. Further elevation of the JVP on inspiration (Kussmaul’s sign) may be observed with a pericardial effusion.
Ascites
History
Symptoms
Onset
Past medical history
Examination
Inspection
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