What are Ascites? Transudate vs Exudate - SAAG - Fluid Wave Test - Shifting Dullness - Treatment

Definition of ascites is the 

accumulation of fluid in the peritoneal or abdominal cavity now the fluid which  accumulates can either be transudate or exudate if you don't know what that means trance today basically has less protein and X today is very protein-rich so as a general rule if the ascites 

fluid is the trans day it tends to mean 

that the reason it happened was because 

of high pressure in the hepatic portal vein and the main causes of this can be things like cirrhosis if the ascites fluid is exudate fluid it's usually due to inflammation and malignancy since it's more protein-rich so we can do this test here called a serum ascites albumin gradient otherwise abbreviated to SI AG and it's used to help determine the cause of ascites because the way to work out is with this formula where you subtract the albumin level of the sciatic fluid to the serum albumin so this formula basically means that you have a total amount of serum albumin and you just subtract the amount of albumin which is in the sciatic fluid and this gives you this gradient here so if you have a high gradient which is for example 11 grams per deciliter that indicate portal hypertension which can either be liver-related or non-liver related this result basically means that 

there's not much protein in the ascites 

so the way that this occurs is we have an increase in hydrostatic pressure in 

the blood vessels of the hepatic portal 

veins and this forces the water into the peritoneal cavity but it leaves the albumin proteins within the vessel so the albumin level of the ascetic fluid will be low so the causes of this type of ascites can be cirrhosis heart failure body Kyary syndrome and portal vein thrombosis with the low gradient result has to be less than 11 grams per deciliter and it's not associated with the increased portal hypertension because there is a lot of protein present within the peritoneal fluid or the ascites the causes of this can be tuberculosis pancreatitis peritoneal cancer and infections so let's talk about the signs and symptoms of ascites we can see from this diagram which you can see here on the right you can see the patient has increased abdominal girth and the reason that happens is just because of the accumulation of the fluid it pushes the abdominal and it appears a lot bigger we also have a test which is known as the 

fluid wave test you can see this 

happening on the right 

basically, you place the patient's hand 

in the middle of the patient's abdomen 

and then you tap from one side of the 

stomach and having your hand in the middle will basically stop any vibrations but with patients who have ascites the vibrations are carried through the fluid which is in the abdominal cavity so when you tap on one side it's felt on the other side and that's a sign of ascites bulging flanks are another sign of ascites so it's where the sides of the abdomen are seen 

to bulge outwards and it's quite unusual 

and it's seen in patients who have a lot 

of fluid in the abdomen it looks like this shifting dullness there's another test that you can do on a patient if you're suspecting ascites it's where you have the patient lie firstly on their back and you're tapping using your fingers over the abdomen trying to find 

signs of dullness while you're tapping 

if you do suspect that there is dullness 

you mark this position and have the 

patient lie on their side in the opposite direction and then you tap in the same place and if it was fluid which was present it should have shifted up in position because that's how fluid is if the dullness is still in that same position then it's likely that it's some kind of abdominal mass or feces however if it was fluid or if it was Societies then you won't hear that dullness when tapping in that same position again 

because the fluid has moved upwards also 

the patient may experience shortness of 

breath because of the increased weight that he's carrying in its abdomen so that can lead to more tightness and shortness of breath you can classify ascites based on how severe it is so grade one is very mild and it's visible and ultrasound and CT scans grade two is detectable with this flank bulging and the shifting dullness and 

 three is directly visible and the 

fluid wave test is positive the causes 

of ascites and numerous so there's quite 

a lot of causes I've listed some of them 

here the ones in green are due to a high 

si AG result so that means the ascites 

fluid is translated so there's not much albumin protein in there so the cause of this can be cirrhosis heart failure body Kyary syndrome constrictive pericarditis and kwashiorkor the ones listed in blue here are due to low si AG cases so they contain a lot of protein these causes can be cancer tuberculosis pancreatitis and Sarah situs nephrotic syndrome and angioedema and we have some rare causes as well such as mic syndrome vasculitis and hyperthyroidism the diagnosis of ascites there's quite a few tests to help distinguish the type of fluid we have the serum ascites albumin gradient test that helps to determine whether it's an exudate fluid or transudate fluid a complete blood count is also done along with the liver enzymes and basic metabolic profile ultrasound is also done to scan the abdomen and an abdominal CT scan is also done as well this is just also to rule out any abdominal masses which may also be present as well the treatment of ascites if it's a high AAG case so it's got a low amount of albumin and it's a transient fluid the cause is basically due to this hypertension so things like reducing salt taking diuretics which counteract the function of aldosterone because aldosterone increases the retention of sodium and excretion of potassium these drugs like spironolactone which counteracts aldosterone are useful drainage and transplant surgery is also considered in low si AG cases which is due to exceed a or higher amounts of protein in the  fluid it doesn't respond to salt or diuretic so the treatment of the underlying cause of the ascites is the most important method.