1. Ascites/Abd Swelling

2. History Increase in belt/clothing size New hernias Pulling/stretch of flank or groin Pain Indigestion/heartburn Tachypnea Orthopnea Alcohol h/o jaundice, hematuria or changes in bowel.

3. Physical Exam Signs of alcoholic cirrhosis Supraclavicular node malignancy

4. Inspections Contour Tense/Tight Skin Bulging flanks Everted umbilicus Prominent venous pattern around umbilicus Doming with visible ridges may be from intestinal obstruction or distention

5. Auscultation Bowel sounds Bruit over liver Rub of surface nodule Venous hum at umbilicus

6. Percussion Fluid Wave Flank dullness that shifts with change in position indicates >1500ml of ascites Distinguish from localized swelling due to uterus, ovarian cyst, or distended bladder Liver Size Free air in peritoneal cavity.

7. Palpation Difficult in ascites Spleen Liver firmness, nodularity Masses Tenderness- inflammation, abscess Rectal/Pelvic exam- masses

8. Imaging Upright and Recumbent plain films U/S CT

9. Laboratory Diagnostic paracentesis Gross appearance Protein Albumen Cell Count/Diff Gram Stain and culture AFB stain and culture Cytology Triglycerides

10. Serum-Ascites Albumin Gradient (SAAG) >97% sensitive >1.1 due to portal hypertension

11. Spontaneous Bacterial Peritonitis (SBP) >250 PMN +GM Stain/Culture Empiric antibiotics in the setting of cirrhosis

12. CHARACTERISTICS OF ASCITIC FLUID IN VARIOUS DISEASE STATES ConditionGross Appearance Protein, g/L Serum- Ascites Albumin Gradient, g/dL Red Blood Cells, >10,000/uL White Blood Cells, per uL Other Tests CirrhosisStraw- colored or bile-stained <25 (95%)>1.11%<250 (90%)a; predominantl y mesothelial NeoplasmStraw- colored, hemorrhagic, mucinous, or chylous >25 (75%)<1.120%>1000 (50%); variable cell types Cytology, cell block, peritoneal biopsy Tuberculous peritonitis Clear, turbid, hemorrhagic, chylous >25 (50%)<1.17%>1000 (70%); usually >70% lymphocytes Peritoneal biopsy, stain and culture for acid-fast bacilli Pyogenic peritonitis Turbid or purulent If purulent, >25 <1.1UnusualPredominantl y polymorphon uclear leukocytes Positive Gram's stain, culture Congestive heart failure Straw- colored Variable, 15- 53 >1.110%<1000 (90%); usually mesothelial, mononuclear NephrosisSStraw- colored or chylous <25 (100%)<1.1Unusual<250; mesothelial, mononuclear If chylous, ether extraction, Sudan staining Pancreatic ascites Turbid, hemorrhagic, or chylous Variable, often >25 <1.1Variable, may be blood- stained Variable Increased amylase in ascitic fluid and serum

13. Pt’s Imaging CT abd/pelvis w oral contrast: Extensive abd ascites with question of underlying cirrhotic liver. Pancreatic head is slightly prominent. No discrete masses seen US abd: large amount of ascites, mild hepatomegaly with patent portal and hepative veins. nL gallbladder

14. Pt’s Labs CBC: 25.5>16.2/48.0<940 BMP: 130/5.3/90/25/39/1.7<141 Ca/Mg/Phos: 9.4/2.8/4.6 LFT: 6.5/2.5/1.4/0.6/52/39<381 PT/INR: 18.2/1.5 Amylase/Lipase: 3993/1452 UA: Clear/Yellow/1.015/5.0/Trace prot Hepatitis panel negative Tox screen negative

15. Ascites WBC: 3300 PMN: 73% RBC: 94 Protein: 4.3 Albumin: 2.1 Amylase: 157,217 Gram Stain: no organisms, many WBCs Cytology negative for malignant cells

16. Pancreatic Ascites High amylase in the ascitic fluid (greater than 1000 IU/L) Increased or normal protein concentration Severe abdominal pain is uncommon. 2-3 times more common in men 20 and 50yo. Chronic Pancreatitis 80% Acute Pancreatitis 8.6% Pancreatic duct dz Treatment Conservative Tx with bowel rest and medical management with octreotide Surgery (varied based on leak) Newer endoscopic treatments with stent placement

17. Pt Update

18. References 1. Gomez-Cerezo J, Cano AB, Suarez I, Soto A, Rios JJ, Vazquez JJ. Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000. Am J Gastroenterol 2003;98:568-77. 2. Parekh D. Segal I. Pancreatic ascites and effusion. Risk factors for failure of conservative therapy and the role of octreotide. Arch Surg 1992;127:707-12. 3. Bracher GA, Manocha AP, DeBanto JR, Gates LK, Slivka A Whitcomb DC, Bleau BL, Ulrich CD, Martin SP. Endoscopic pancreatic duct stenting to treat pancreatic ascites. Gastrointest Endosc 1999;49:710-5. 4. Harrisons Principles of Internal Medicine. Abdominal Swelling and Ascites. Ch. 44Text Book