1. Ascites and abdominal swelling Int jeerawat silasuwan MD

2. Clincal history progressive increase in belt or clothing size insidious onset, without pain coexistent obesity flank, groins, low back pain localized pain [ congestived liver, large spleen, or colonic tumor ] Pain is uncommon in cirrhosis except pancreatitis, HCC,peritonitis progressive increase in belt or clothing size insidious onset, without pain coexistent obesity flank, groins, low back pain localized pain [ congestived liver, large spleen, or colonic tumor ] Pain is uncommon in cirrhosis except pancreatitis, HCC,peritonitis

3. Clincal history Increase intra-abdominal pressure  GERD, dyspnea, orthopnea, tachypnea Hepatic hydrothorax  leakage through lymphatic chanels Increase intra-abdominal pressure  GERD, dyspnea, orthopnea, tachypnea Hepatic hydrothorax  leakage through lymphatic chanels

4. Physical examination Inspection Ascites – tensely abdomen,tightly stretched skin, bulging flanks, everted umbilicus Venuos pattern – obstruction IVC flow lower part to umbilicus - obstruction SVC flow upper part to umbilicus Inspection Ascites – tensely abdomen,tightly stretched skin, bulging flanks, everted umbilicus Venuos pattern – obstruction IVC flow lower part to umbilicus - obstruction SVC flow upper part to umbilicus

5. Physical examination Auscultation High pitched,rushing sound  gut obstruction Succussion sound  increase fluid in hallow viscus Harsh bruit at liver  HCC or vascular tumor,friction rub  liver metastasis Venous hum at umbilicus  portal HT Auscultation High pitched,rushing sound  gut obstruction Succussion sound  increase fluid in hallow viscus Harsh bruit at liver  HCC or vascular tumor,friction rub  liver metastasis Venous hum at umbilicus  portal HT

6. Physical examination Percussion Generalized abdominal swelling, careful localized swelling  uterus mass,ovarian cyst,ditended bladder Shifting dullness Percussion Generalized abdominal swelling, careful localized swelling  uterus mass,ovarian cyst,ditended bladder Shifting dullness

8. Physical examination Palpation Sister Mary Joseph nodule Palpation Sister Mary Joseph nodule

10. Radiographic examinations

17. conditiongrass proteinSAAGRBC >1000 WBCother cirrhosis Straw,bile <25>1.11% <250 neoplasm Straw,blood, mucus, chylous >25<1.120% >1000 cyto TB Clear,turbid, bloody, chylous >25<1.17% >1000 L>70% AFB Pyogenic peritonitis Turbid,pus >25<1.1 rarePMN gram

18. conditiongrass proteinSAAGRBC >1000 WBCother CHF Straw 15-53 >1.110% <1000 Mesothium,mono nephrosis Straw, chylous <25<1.1rare <250 sudan Pancreatitic ascites Turbid, Bloody, chylous variable >25 <1.1 Variable May be bloody variable amylase

19. Chylous ascites Turbid,milky,creamy Sudan staining fat globule Increase TG >1000 mg/dL Pseudochylous  WBC, tumor Test  alkali  lysis cell Lymphatic obstruction-> trauma,tumor,TB,filariasis,nephrotic syndrome Turbid,milky,creamy Sudan staining fat globule Increase TG >1000 mg/dL Pseudochylous  WBC, tumor Test  alkali  lysis cell Lymphatic obstruction-> trauma,tumor,TB,filariasis,nephrotic syndrome

20. Mucinous ascites Pseudomyxoma peritonei Rare colliod CA Pseudomyxoma peritonei Rare colliod CA

21. SAAG SAAG > 1.1 mg/dl Cirrhosis Alcoholic Hepatitis Cardiac Ascites Massive Liver Metastasis Fulminant Hepatic Failure Budd-Chiari Syndrome Portal Vein Thrombosis Veno-Occlusive Disease Myxedema Fatty Liver of Pregnancy SAAG > 1.1 mg/dl Cirrhosis Alcoholic Hepatitis Cardiac Ascites Massive Liver Metastasis Fulminant Hepatic Failure Budd-Chiari Syndrome Portal Vein Thrombosis Veno-Occlusive Disease Myxedema Fatty Liver of Pregnancy SAAG < 1.1 mg/d Peritoneal Carcinomatosis Tuberculous Peritonitis Pancreatic Ascites Bowel Obstruction Biliary Ascites Posteroperative Lymphatic Leak Serositis in Connective Tissue Disease nephrosis