Diagnostic Imaging Pathways - Ascites
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This pathway provides guidance on how to image suspected ascites and determine its cause.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: January 2012
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
![]() | None | 0 |
![]() | Minimal | < 1 millisieverts |
![]() | Low | 1-5 mSv |
![]() | Medium | 5-10 mSv |
![]() | High | >10 mSv |
Images
Teaching Points
Teaching Points
- In suspected ascites, ultrasound is highly sensitive in confirming or refuting the diagnosis
- Ultrasound may show the cause of ascites, such as cirrhosis and portal hypertension or peritoneal metastases
- Ultrasound can guide diagnostic paracentesis for fluid analysis and cytology
ascites
Causes of Ascites
- Causes of ascites 17
- Cirrhosis - 81%
- Cancer - 10%
- Heart failure - 3%
- Tuberculosis - 2%
- Dialysis - 1%
- Pancreatic disease - 1%
- Other - 2%
Cirr_PH
Causes Of Cirrhosis And Portal Hypertension Seen On Ultrasonography
- Aetiology of hepatic cirrhosis 18
- Alcohol (60-70 percent)
- Chronic hepatitis B or C (5-10 percent)
- Biliary obstruction (5-10 percent)
- Haemochromatosis (5-10 percent)
- NASH (10 percent)
- Other
- Auto-immune
- Drugs and toxins
- Genetic metabolic disease
ct
Computed Tomography (CT)
- Uses and features include:
- Often has a complementary role with ultrasound in the evaluation of patients with ascites
- Is a sensitive tool for the detection of ascites 4
- Provides a more complete evaluation of the abdomen and pelvis which is particularly useful in patients with an unknown source of ascites 3
- Unlike ultrasound is not impeded by a large amount of bowel gas
- Disadvantages
- Involves exposure to radiation
- Risk of contrast allergy and nephropathy if intravenous contrast is used
diagpara
Diagnostic Paracentesis
- Is useful for 5
- Confirming the presence of ascites
- Determining the cause of ascites
- Determining whether the fluid is infected
- Determining whether portal hypertension is present
- A serum - ascitic albumin gradient (SAAG) >11g/l indicates ascites due to portal hypertension
- A serum - ascitic albumin gradient (SAAG) <11g/l indicates ascites due to other causes
- Best done under ultrasound guidance if
- There is only a small amount of fluid
- The fluid is loculated
- The patient has a gross coagulopathy or multiple scars
- After a failed paracentesis done without ultrasound guidance
doppler
Ultrasound
- Uses and features include
- Can confirm the presence of ascites as physical examination is only moderately accurate for diagnosis 1
- Can detect as little as a few millilitres of fluid located anterior to the liver or immediately below the diaphragm 2,3
- Can help determine the cause of ascites such as portal hypertension, cirrhosis, portal and hepatic vein thrombosis 4,6
- Can guide paracentesis and is particularly useful where there is only a small amount of fluid or the fluid is compartmentalised 4,5
- Has a sensitivity and specificity of at least 85% for the diagnosis of Budd-Chiari syndrome 8
- Ultrasound features of portal hypertension include 14
- Collateral vessels - commonly gastroesophageal, paraumbilical, splenorenal and gastrorenal veins 10,11
- Enlarged splanchnic veins 12
- Portal and splenic veins greater than 10mm in diameter (sensitivity and specificity of 82%) 13
- A patent paraumbilical vein (specificity of 100% and sensitivity of 82%) 15
- Ultrasound features of liver cirrhosis include 14
- A coarsened, heterogeneous echo pattern
- Increased parenchymal echogenicity
- Nodularity of liver surface
- Limitations of ultrasound include 7
- Poor beam penetration in obese patients and those with multiple air-filled bowel loops
- Low specificity for characterising liver lesions
- Operator dependent
liver-biop
Liver Biopsy
- Referral for liver biopsy should be considered after a thorough non-invasive clinical, serological and radiological evaluation has failed to establish a cause of liver cirrhosis. Due consideration must given to the risk/benefit profile prior to considering biopsy, as well as how biopsy results would change management 18
- In a large prospective study which performed 354 liver biopsies for sustained abnormal liver function tests, 18% of patients had their management directly altered by the outcome of the biopsy 19
- There is a significant false negative rate (10-50%) with percutaneous liver biopsy in the diagnosis of cirrhosis. Newer procedures that incorporate mini-laproscopic techniques with direct visualisation of the liver has reduced this rate (15%) 20
no_PH_Cirr
Causes Of Portal Hypertension With No Evidence Of Cirrhosis
- Causes of portal hypertension with no evidence of cirrhosis
- Alcoholic hepatitis
- Congestive cardiac failure
- Massive hepatic metastasis
- Constrictive pericarditis
- Budd-Chiari syndrome
- The Budd-Chiari Syndrome (BCS) refers to obstruction of hepatic venous outflow by a group of heterogeneous disorders 8,12
- Causes include 16
- Hypercoagulable states
- Tumour invasion
- Idiopathic
- Doppler ultrasound has a sensitivity and specificity of at least 85% for the diagnosis and is the initial imaging modality of choice if the Budd-Chiari syndrome is suspected 17
- CT can assist in the diagnosis and compared to ultrasound, provides a more complete assessment of the abdomen
- Hepatic venography is recommended if there is a strong clinical suspicion of Budd-Chiari syndrome, in the setting of a negative or inconclusive ultrasound result. The classical "spiderweb" pattern is often diagnostic 16
portal
Ultrasound Features Of Portal Hypertension
- Ultrasound features of portal hypertension include 14
- Collateral vessels - commonly gastroesophageal, paraumbilical, splenorenal and gastrorenal veins 10,11
- Enlarged splanchnic veins 12
- Portal and splenic veins greater than 10mm in diameter (sensitivity and specificity of 82%) 13
- A patent paraumbilical vein (specificity of 100% and sensitivity of 82%) 15
super_asc
Causes Of Ascites In A Patient Known To Have Cirrhotic Liver Disease
- Causes of ascites in a patient known to have cirrhotic liver disease 9
- Progression of the underlying liver disease
- Superimposed liver injury (such as alcoholic or viral hepatitis)
- Development of hepatocellular carcinoma
- Vascular thrombosis
- Spontaneous bacterial peritonitis
- Change to medications/diet
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Cattau EL, Benjamin SB, Knuff TE, Castell DO. The accuracy of the physical examination in the diagnosis of suspected ascites. JAMA. 1982;247:1164-6. (Level III evidence)
- Goldberg BB, Goodman GA, Clearfield HR. Evaluation of ascites by ultrasound. Radiology. 1970;96:15-22. (Level II evidence). View the reference
- Thoeni RF. The role of imaging in patients with ascites. AJR Am J Roentgenol. 1995;165:16-8. (Review article)
- Olafsson S, Blei AT. Diagnosis and management of ascites in the age of TIPS. AJR Am J Roentgenol. 1995;165:9-15. (Review article)
- Runyon BA. Management of adult patients with ascites due to cirrhosis. Hepatology. 1998;27:264-72. (Review article)
- Malik A, Saxena NC. Ultrasound in abdominal tuberculosis. Abdom Imaging. 2003;28:574-9. (Level III evidence)
- Taylor HM, Ros PR. Hepatic Imaging. Radiol Clin North Am. 1998;36:237-45. (Review article)
- Bolondi L, Gaiani S, Li Bassi S, et al. Diagnosis of Budd-Chiari syndrome by pulsed Doppler ultrasound. Gastroenterology. 1991;100:1324-31. (Level III evidence)
- Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudates-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992;117:215-20. (Level III evidence)
- Vilgrain V, Lebrec D, Menu Y et al. Comparison between ultrasonographic signs and the degree of portal hypertension in patients with cirrhosis. Gastrointest Radiol. 1990;15:218-22. (Level III evidence)
- Subramanyam BR, Balthazar EJ, Madamba MR, et al. Sonography of portosystemic venous collaterals in portal hypertension. Radiology. 1983;146:161-6. (Level III evidence)
- Vilgrain V. Ultrasound of diffuse liver disease and portal hypertension. Eur Radiol. 2001;11:1563-77. (Review article)
- Sharma MP, Dasarathy S, Misra SC, Saksena S, Sundaram KR. Sonographic signs in portal hypertension: a multivariate analysis. Trop Gastroenterology. 1996;17:23-9. (Level III evidence)
- Brown JJ, Naylor MJ, Yagan N. Imaging of liver cirrhosis. Radiology. 1997;202:1-16. (Review article)
- Gibson RN, Gibson PR, Donlan JD, Clunie DA. Identification of a patent paraumbilical vein by using Doppler sonography: importance in the diagnosis of portal hypertension. AJR Am J Roentgenol. 1989;153:513-6. (Level II evidence). View the reference
- Narayanan Menon KV, Shah V, Kamath PS. Current concepts. the Budd-Chiari syndrome. N Engl J Med. 2004;350:578-85. (Review article)
- Kamath PS. Budd Chiari syndrome: radiological findings. Liver Transpl. 2006;12(11 Suppl 2):S21-2. (Review article)
- Heidelbaugh J, Bruderly M. Cirrhosis and chronic liver failure. Part I diagnosis and evaluation. Am Fam Physician. 2006;74:756-62. (Review article)
- Skelly M, James P, Ryder S. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol. 2001;35:195-9. (Level II Evidence). View reference
- Helmreich-Becker I, Schimascher P, Denzer U. Minilaproscopy in the diagnosis of cirrhosis: superiority in patients with child-pugh A and macronodular disease. Endoscoopy. 2003;35:55-60. (Level IV evidence)
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