00:00
Now, let's talk about ascites.
00:01
It's really important
to be able to identify ascites
especially in folks who have
chronic liver disease
because the presence of ascites
in a person who has
chronic liver disease
and has a little bit of
abdominal pain
may be concerning for SBP,
Spontaneous Bacterial Peritonitis,
which can be a potentially
devastating condition
if not detected
and if you don't do
an abdominal paracentesis
to look for it.
00:25
So very important for us to be able
to assess this at the bedside,
because you can't always
get an ultrasound up there
quickly to do that.
00:32
So we're going to review
a couple of tests for ascites.
00:35
First off, again, the person
should have chronic liver disease,
you're not really worried about
spontaneous bacterial peritonitis
and somebody without that,
though, ascites can be caused by
a variety of other things
other than liver disease,
for example,
patients with
metastatic ovarian cancer
could have ascites as well.
00:52
In general, folks with ascites
from liver disease
are going to have
peripheral edema.
00:56
So that can be an
important marker
that would suggest
the presence of ascites,
if there is distension,
in the belly,
again, those bulging flanks
we were talking about earlier.
01:04
in the absence of
peripheral edema,
it's somewhat less likely
to be ascites in the abdomen.
01:10
But now let's look at some
specific findings in the belly.
01:14
So first off, we talked before about
how as you move towards the back,
you're going to have dullness
because the retroperitoneal organs
are all dull. So down here,
-can you just slide
your arm over; thanks-
it's going to be more
dullness back here
compared with up here,
right?
In patients who have a lot of
fluid in the belly from ascites
the water is heavier
than the intestines,
so, it basically forms
a pool of water
all the way across the abdomen, with
the intestines rising to the top.
01:48
So you'd have only tympany in this
upper area, this upper circle
and a line of dullness
heading towards the flanks.
01:58
As opposed to in this case,
you've got some tympany here,
a little bit dullness there,
some tympany there,
there's not like a clear line,
distinguishing between
air and liquid.
02:09
Instead, there's just
this kind of vague line
where the intestines and
the retroperitoneal organs begin.
02:17
So, flank dullness,
when we talk about flank dullness
as a sign of ascites,
we're talking about
a line of dullness.
02:26
Next up,
we want to see if that line moves
when you move the body
because if it is actually
like a balloon filled with water,
as we rotate the balloon,
the line of water
should stay in the same place
even as the balloon itself
is rotating.
02:40
So, if I may just make
a little mark.
02:44
Let's say that she did have
a line of dullness here.
02:50
She doesn't,
but I'm going to make a mark.
02:51
She has a line of dullness
right there.
02:54
As I rotate her on to your
left hip, please.
02:58
You could rotate
on to your left hip.
03:00
- Okay. This way?
- Yes.
03:05
After a minute or so
of that fluid settling,
it'll now be settled down
to the left side of her abdomen.
03:13
And that line of dullness
is very simple gravity
working on water
will now rise up,
because now we
have that lake of fluid
is on the lower half of the
dependent position that she's in.
03:25
So, I would instead find
that if I started percussing,
I would find dullness down here,
I would put a new mark,
let's say here.
03:38
Now, you can roll back over
towards me.
03:41
When you have so-called
shifting dullness,
that is that line moved medially,
that is a strong likelihood
of having ascites.
03:52
And the last test
we would look for ascites
is called the fluid wave.
03:55
This oftentimes requires
another person to come
and help you do the test.
03:59
But it's based on the idea that
if there's a leak of fluid in there
and I push on one side,
I should feel a wave of fluid
hit my fingers on the other side.
04:06
So it's simply
applying pressure from here,
I've got my right hand here
as a detector.
04:12
And I'm pushing like that.
04:14
And I'm not looking for just
soft tissue kind of moving over,
I'm looking for really
that feeling of water
having a wave that comes
into your hand.
04:23
So that's called the fluid wave.
04:25
And folks who have
a lot of adiposity,
it's useful to have
a third person sort of
put their hand on the top here
to prevent the soft tissue
from confusing things.
04:33
But in a thin patient,
it's easy enough to just do that.
04:36
And in this case, I'm not feeling
any evidence of any fluid wave
coming against my fingers.
04:40
So, those are all useful tests
at the bedside
to look for ascites.
04:45
Now, let's move on
to talk about cirrhosis itself.
04:48
There are dozens of
different interesting findings
that can come along with cirrhosis,
so called the stigmata of cirrhosis.
04:57
There's some that are
diagnostically useful
and some that are just
historical interesting.
05:00
We're going to focus on
the first group now.
05:04
We've already talked about
the presence of Ascites.
05:06
That would of course support
the diagnosis of cirrhosis
as would Peripheral edema.
05:10
Other potential findings,
we'll start head to toe.
05:13
So patients with cirrhosis
oftentimes have Spider angiomata.
05:17
These are a little spider shaped,
dilated capillaries
that are oftentimes on the chest,
sometimes on the cheeks,
and certainly the upper arms.
05:27
You tend to not see them
much farther down.
05:28
I mean characteristic
feature is that
if you push on one,
and release your finger,
you'll see it fill
from the inside out.
05:35
So, it'll blanch and then
it'll fill from the inside out,
and there'll be scattered
on the chest.
05:40
So the next finding would be
Gynecomastia.
05:42
Now, in a woman that's going to be
impossible to distinguish between
actually just breasts that are
present versus gynecomastia.
05:48
Whereas in men,
men who have cirrhosis
have excess estrogen levels,
which contribute
to a lot of these findings.
05:58
There's also a diminished
clearance of progesterone,
or metabolism of progesterone
and all these things contribute
to some of these manifestations.
06:06
And in men, you'll have
what's called gynecomastia,
which is the production
of glandular breast tissue
around the nipples
around the areola.
06:14
And you can distinguish that
from obesity.
06:16
Patients who are obese
may have enlarged breasts,
but there won't actually be
any glandular tissue,
any that indurated thick and firm
tissue around the areola.
06:26
Whereas, in gynecomastia
from cirrhosis,
there's actual
breast tissue there.
06:30
There are glands, glandular tissue
around the areola,
so that's a distinguishing
characteristic.
06:38
Next up is the so-called
Caput medusae sign.
06:41
Folks who have portal hypertension
specifically
in the setting of progressed
or advanced cirrhosis,
are going to have
dilated umbilical veins,
and it's called caput medusae
because of this sort of
looks like little spiders,
or a little snakes coming off
of the head of Medusa,
due to this engorgement of
these umbilical vessels.
07:01
It's normal to have
umbilical vessels, of course.
07:04
Those are the veins that are
draining your abdominal wall,
but in the setting of cirrhosis
with portal hypertension,
fluid can't go forward
pass the liver into the IVC.
07:14
So it finds other ways to end up
getting back towards the heart.
07:18
So, you'd see this dilation
of the umbilical vessels.
07:21
Next up, let's head
towards the extremities.
07:24
Patients with cirrhosis,
oftentimes
will have what's called
Terry's nails,
where 80% of the nail plate
is has turned white
or leukonychia is present.
07:35
And the distal nail bed
is kind of a reddish brown.
07:40
So, it's 80% white versus 20%
are reddish brown in coloration.
07:46
And that's present in a number
of folks with cirrhosis.
07:50
And while this is not exactly
a marker of cirrhosis itself,
it's a diagnosis of one of the
complications of cirrhosis
portosystemic encephalopathy,
and that's asterixis,
which is something
we look for all the time
and folks when
we're concerned about
uremic encephalopathy or
portosystemic encephalopathy.
08:06
So what I'm going to have
you do now, Shayla
is just put your hands up
in front of you, like this,
like you're stopping traffic.
08:13
Patients with asterixis will develop
what's called a liver flap.
08:16
We're just have your hand
kind of floppy that for me.
08:19
That's a classic picture
of asterixis.
08:21
You can put your hands
down now.
08:23
You can actually do that in any
muscle group in the body,
where the patient has to
maintain muscular contraction.
08:29
In some ways,
it's the opposite of myoclonus.
08:31
Myoclonus is a patient at rest with
spontaneous muscle contractions.
08:35
Asterixis is a patient
actively contracting muscles
and spontaneously losing tone
in those muscle groups.
08:42
And you can even have a person
stick out their tongue
and look for asterixis.
08:45
It's any muscle group will work.
08:50
In addition on the hands,
patients with cirrhosis
may have Palmer erythema.
08:54
This is again has to do
with the estrogenization
and folks with cirrhosis
where in particular
on the thenar and hypothenar
eminence
you may see some
blanching erythema on those areas.
09:06
Patients with cirrhosis
may have Scleral icterus
depending upon what's going on
with their liver at the time.
09:12
Some with certainly
alcohol induced hepatitis
could have an
acutely elevated bilirubin
that would be manifest
in their sclera,
if they have a bilirubin of at least
3 or 4 milligrams per deciliter.
09:28
You may also see icterus
even under the tongue
in patients with jaundice.