Bulging flanks

Abstract: ASCtTES is an abnormal collection of fluid within the peritoneal cavity. The clinical presence of ascites is suggested by physical signs, including abdominal distention with bulging flanks, a palpable fluid wave, and shifting dullness to percussion. Small amounts of ascitic fluid often are difficult to detect by physical findings, and ultrasonography (US) has become the best procedure to confirm or disprove the presence of ascites in patients who have mild abdominal distent ion) Massive ascites, in contrast, is documented readily by physical examination, and usually the etiology is apparent after a complete history and thorough physical examination. 2 During the evaluation of patients who have obvious ascites, those conditions that produce the physical signs of ascites without actual peritoneal fluid accumulation may not be considered. The term pseudoascites denotes the clinical impression of ascites when, in fact, free fluid is not present within the peritoneal cavity. Our experience with pseudoascites and a literature review prompted us to summarize the reported conditions that may produce pseudoascites. Proper management of these conditions underscores the need to consider imaging studies before invasive diagnostic procedures are performed, especially if the cause of the "ascites" is unclear.

Abstract: To the Editor. —The article by Drs Williams and Simel1is a laudable contribution to the study of bedside diagnosis to whichJAMAhas wisely made a commitment. I would like to add some additional comments concerning the diagnosis of ascites by physical examination. In my experience, the combination of abdominal distention, bulging flanks, and an everted umbilicus is almost always due to ascites. Rarely, false positives such as a large ovarian cyst will produce this sign. Unfortunately, the sign of the everted umbilicus has not been subjected to rigorous study. A valuable technique taught by Jack Myers, MD, (famed clinician and professor emeritus at the University of Pittsburgh [Pa]) consists of placing the examiner's hands, volar side up, under both bulging flanks of the supine patient, followed by flicking the flanks upward a few inches. If ascites is present, a fluid wave will be felt falling into the

Abstract: Ascites is diagnosed on physical exam by findings of abdominal distension, bulging flanks, shifting dullness and a prominent fluid wave. However, as the following cases demonstrate, these signs may also be positive in pseudoascites due to thick layers of adipose tissue in the abdomen. A history of recent food binging and a lack of a prolonged prothrombin time should raise the index of suspicion for pseudoascites in a patient with a protuberant abdomen. In light of equivocal physical signs, physicians may employ ultrasonography to prevent patients with pseudoascites from suffering multiple futile attempts at paracentesis.

Abstract: The diagnosis of ascites can be made very likely by a good clinical history and a well-directed physical examination, if the patient suffers from a disease which can cause ascites. The physician should ask about recent weight gain, change in abdominal girth and ankle oedema. With a positive history, the likelihood of the presence of ascites may increase 3 to 4-fold. When the findings at physical examination are also positive, the likelihood may increase 10 to 20-fold. A fluid wave is the most specific but less sensitive symptom. Shifting dullness, bulging flanks and flank dullness are less specific but much more sensitive parameters. The presence of ascites is very unlikely if the prior probability is low and both the patient's answers and the findings at physical examination are negative. Abdominal ultrasound, the gold standard, is not strictly indicated for diagnosing ascites: if based on the trial tried: pretest probability, clinical history and physical examination, the diagnosis is very likely or very unlikely. Ultrasonography is always indicated, however, when ascites is suspected and a positive finding is of clinical relevance.