The physical examination in a patient with ascites should focus on the signs of portal hypertension and chronic liver disease. Note the following:
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Physical findings suggestive of liver disease include jaundice, palmar erythema, and spider angiomas.
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The liver may be difficult to palpate if a large amount of ascites is present, but if palpable, the liver is often found to be enlarged. The puddle sign may be present when as little as 120 mL of fluid is present. When peritoneal fluid exceeds 500 mL, ascites may be demonstrated by the presence of shifting dullness or bulging flanks. A fluid-wave sign is notoriously inaccurate.
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Elevated jugular venous pressure may suggest a cardiac origin of ascites. A firm nodule in the umbilicus, the so-called Sister Mary Joseph nodule, is not common but suggests peritoneal carcinomatosis originating from gastric, pancreatic, or hepatic primary malignancy.
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A pathologic left-sided supraclavicular node (Virchow node) suggests the presence of upper abdominal malignancy.
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Patients with cardiac disease or nephrotic syndrome may have anasarca.
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This computed tomography scan demonstrates free intraperitoneal fluid due to urinary ascites.
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Transjugular intrahepatic portosystemic shunt (TIPS).
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Massive ascites.
