Ascites & Venous Patterns
When liver disease is severe enough to cause cirrhosis, the increase in portal hypertension can lead to backup of flow through the liver. This may lead to fluid in the abdomen (ascites) and unique venous patterns on the abdomen that can vary depending on the diagnosis.
Shifting Dullness with Ascites
- Begin percussing in the center or most protuberant part of the abdomen. You should hear tympany from air in the loops of bowel that have floated up.
- Percuss laterally towards you from that point till you encounter dullness. KEEP YOUR FINGERS THERE.
- Ask patient to turn to the side away from you. Wait a few seconds (for fluid to move to the new dependent area and for bowel to float up).
- Now when you percuss it should be tympanitic.
Fluid Thrill or Wave in Ascites
- Ask pt or assistant to press the edge of one hand vertically down the midline of the abdomen.
- Tap or flick one flank sharply with fingertips while palm of the other hand is resting on the other flank.
- The positive finding is a “thrill” which is a better descriptor than wave.
- Because cirrhosis is the most common cause of ascites, many patients with ascites demonstrate the stigmata of liver disease.
- An elevated JVP suggests a cardiac cause (e.g. heart failure, constrictive pericarditis) of ascites.
Abdominal Venous Patterns
- Need to distinguish three kinds of flow in visible veins.
- Flow away from the umbilicus (portal hypertension).
- Flow to the umbilicus (rare, in portal vein thrombosis).
- Flow from down to up (IVC obstruction).
Key Learning Points
- Learn how to test for shifting dullness
- Learn how to test for a fluid wave
- Describe abdominal venous patterns
The Stanford Medicine 25
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