Chapter 044. Abdominal Swelling and Ascites (Part 1) Harrison's Internal Medicine > Chapter 44. Abdominal Swelling and Ascites Abdominal Swelling Abdominal swelling or distention is a common problem in clinical medicine and may be the initial manifestation of a systemic disease or of otherwise unsuspected abdominal disease. Subjective abdominal enlargement, often described as a sensation of fullness or bloating, is usually transient and is often related to a functional gastrointestinal disorder when it is not accompanied by objective physical findings of increased abdominal girth or local swelling. Obesity and lumbar lordosis, which may be associated with prominence of the abdomen, may usually be distinguished from true increases in the volume of the peritoneal cavity by history and careful physical examination. Clinical History Abdominal swelling may first be noticed by the patient because of a progressive increase in belt or clothing size, the appearance of abdominal or inguinal hernias, or the development of a localized swelling. Often, considerable abdominal enlargement has gone unnoticed for weeks or months, either because of coexistent obesity or because the ascites formation has been insidious, without pain or localizing symptoms. Progressive abdominal distention may be associated with a sensation of "pulling" or "stretching" of the flanks or groins and vague low back pain. Localized pain usually results from involvement of an abdominal organ (e.g., a passively congested liver, large spleen, or colonic tumor). Pain is uncommon in cirrhosis with ascites, and when it is present, pancreatitis, hepatocellular carcinoma, or peritonitis should be considered. Tense ascites or abdominal tumors may produce increased intraabdominal pressure, resulting in indigestion and heartburn due to gastroesophageal reflux or dyspnea, abdominal wall hernias (inguinal and umbilical), orthopnea, and tachypnea from elevation of the diaphragm. A coexistent pleural effusion, more commonly on the right, presumably due to leakage of ascitic fluid through lymphatic channels in the diaphragm, may also contribute to respiratory embarrassment. A large pleural effusion, obscuring most of the lung, is known as a hepatic hydrothorax. The patient with diffuse abdominal swelling should be questioned about increased alcohol intake, a prior episode of jaundice or hematuria, or a change in bowel habits. Such historic information may provide the clues that will lead one to suspect an occult cirrhosis, a colonic tumor with peritoneal seeding, congestive heart failure, or nephrosis. Approach to the Patient: Abdominal Swelling A carefully executed general physical examination can yield valuable clues concerning the etiology of abdominal swelling. Thus palmar erythema and spider angiomas suggest an underlying cirrhosis, while supraclavicular adenopathy (Virchow's node) should raise the question of an underlying gastrointestinal malignancy. Inspection of the abdomen is important. By noting the abdominal contour, one may be able to distinguish localized from generalized swelling. The tensely distended abdomen with tightly stretched skin, bulging flanks, and everted umbilicus is characteristic of ascites. A prominent abdominal venous pattern with the direction of flow away from the umbilicus is often a reflection of portal hypertension; venous collaterals with flow from the lower part of the abdomen toward the umbilicus suggest obstruction of the inferior vena cava; flow downward toward the umbilicus suggests superior vena cava obstruction. "Doming" of the abdomen with visible ridges from underlying intestinal loops is usually due to intestinal obstruction or distention. An epigastric mass, with evident peristalsis proceeding from left to right, usually indicates underlying pyloric obstruction. A liver with metastatic deposits may be visible as a nodular right upper quadrant mass moving with respiration. Auscultation may reveal the high-pitched, rushing sounds of early intestinal obstruction or a succussion sound due to increased fluid and gas in a dilated hollow viscus. Careful auscultation over an enlarged liver occasionally reveals a harsh bruit signifying a vascular tumor (especially a hepatocellular carcinoma) or alcoholic hepatitis, or the leathery friction rub of a surface nodule. A venous hum at the umbilicus may signify portal hypertension and an increased collateral blood flow around the liver. A fluid wave and flank dullness that shifts with change in position of the patient are important signs that indicate the presence of peritoneal fluid, although a minimum of 1500 mL of fluid is usually required to produce these findings. In obese patients, small amounts of fluid may be difficult to demonstrate and often can only be detected by ultrasound examination of the abdomen, which can detect as little as 100 mL of fluid. Careful percussion should serve to distinguish generalized abdominal enlargement from localized swelling due to an enlarged uterus, ovarian cyst, or distended bladder. Percussion can also outline an abnormally small or large liver. Loss of normal liver dullness may result from massive hepatic necrosis; it also may be a clue to free gas in the peritoneal cavity, as from perforation of a hollow viscus. . Chapter 044. Abdominal Swelling and Ascites (Part 1) Harrison's Internal Medicine > Chapter 44. Abdominal Swelling and Ascites Abdominal Swelling Abdominal swelling or. considered. Tense ascites or abdominal tumors may produce increased intraabdominal pressure, resulting in indigestion and heartburn due to gastroesophageal reflux or dyspnea, abdominal wall. the Patient: Abdominal Swelling A carefully executed general physical examination can yield valuable clues concerning the etiology of abdominal swelling. Thus palmar erythema and spider angiomas