Churchills Pocketbook of Differential Diagnosis

ASCITES 35
SUBASH KC/NMC-15TH/2014
to feel masses in the presence of gross ascites. Hepatomegaly and
splenomegaly can occur with portal hypertension and hepatic
and haematological malignancies. Displacement of the apex beat
with cardiomegaly may result from cardiac failure. Pedal oedema
occurs with cirrhosis, cardiac failure, malabsorption, obstruction
of lymphatic flow due to intra-abdominal or pelvic tumours, and
nephrotic syndrome.
Auscultation
A third heart sound, systolic murmurs (functional tricuspid and mitral
regurgitation) and crepitations (pulmonary oedema) may be audible
with cardiac failure. Heart sounds are muffled with pericardial
effusions. A pericardial friction rub or knock is occasionally audible
in pericarditis.
Percussion
Dullness of the lung bases occurs with pulmonary oedema and
pleural effusions (which may occur secondary to ascites).
Internal examination
A rectal examination may reveal ulceration or a fixed mass
suggestive of a carcinoma. In women, an adnexal mass PV may be
the first indication of a pelvic tumour.
GENERAL INVESTIGATIONS
History and examination findings may reveal the underlying cause.
General investigations can be used to confirm or indicate the
possible aetiology.
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Urine dipstick
Will be strongly positive for protein in nephrotic syndrome. If
so, a 24-hour urine collection for protein should be undertaken:
more than 3.5 g/24 h is indicative of nephrotic syndrome.
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FBC
A raised white count may indicate an infective aetiology but a
differential white count is more specific.
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U&Es
Elevated urea and creatinine implies severe renal impairment,
and may occur as a component of hepatorenal syndrome, which
is renal impairment secondary to liver failure.
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LFTs
May be deranged in the presence of liver disease. The serum
albumin will be able to indicate hypoalbuminaemia but the
underlying cause must still be sought.
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CXR
Findings suggestive of cardiac failure are cardiomegaly, upper
venous diversion of blood, the presence of Kerley B lines,
Section A