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I am unable to palpate the liver and it has a span of 12 cm in the right mid-clavicular line.
The spleen is not palpable or percussible. The kidneys are not ballotable. There are no
other masses palpable in the abdomen.
There are no stigmata of chronic liver disease such as leukochynia, clubbing, palmar
erythema, spider naevi, gynaecomastia or loss of axillary hair. There is also no hepatic
fetor or a hepatic flap. Patient is not jaundice and there is no conjunctival pallor.
There is associated pedal edema up to the knee level with sacral edema but no periorbital
edema. There are no signs of renal failure such as a sallow appearance or uremic fetor.
Patient also does not have any features to suggest hypothyroidism such as a cream and
peaches complexion, macroglossia, hoarseness of voice or bradycardia.
He is not cachexic looking and there are no palpable cervical LNs. He is not toxic
looking.
In summary, this patient has got gross ascites that is not associated with any intra-
abdominal organomegaly or masses of which no apparent cause is found clinically. The
possible differential diagnoses include cirrhosis of the liver, Budd-chiari syndrome,
nephrotic syndrome or protein-losing enteropathy, congestive cardiac failure or intra-
abdominal malignancy or TB.
Questions
What are the causes of abdominal distention?
Fat, fluid, flatus, faeces, fetus and organ enlargement
What is ascites?
Pathologically accumulation of fluid in the peritoneal cavity
How would you manage a patient with ascites secondary to cirrhosis of the liver?
Treat the underlying cause
Avoid alcohol or medications that are toxic to liver
Management of ascites
o General measures
Salt restriction <2 g/day
Fluid restriction <1l/day (for ascites, edema with Na <130)
o Specific measures
Diuretics (Spironolactone, frusemide initially)
Aim to 0.5kg/day if no peripheral edema
Aim 1kg/day if presence of peripheral edema also
Increase diuretics with spironolactone up to 400mg/d or frusemide
160mg/d
Paracentesis
If >5L then requires albumin administration (8g per L of fluid
removed)
TIPSS (Transjugular Intrahepatic portosystemic shunt)
High rate of shunt stenosis; up to 75% at 1 year
o Liver transplant
5 year survival rate for cirrhosis with ascites is 30-40% vs 70-80% for post
liver transplant
MELD score (Model for End Stage liver disease which has bilirubin,
creatinine and INR)
Consider for those with refractory ascites, SBP or HRS
Manage other complications of cirrhosis
What does development of ascites in a patient with cirrhosis of the liver means?
Decompensation
Occurs in 50% of patients within 10 years of diagnosing compensated cirrhosis
Poor Px
o only 50% survive beyond 2 years
o poor quality of life
o increased risk of infection and renal failure