Physical Exam: Liver & Ascites

There are many other physical findings to look for in the patient with ascites:

Skin:

• Palmar erythema
• Spider angiomata - most commonly on the trunk and upper extremities
• Caput medusae (dilated venous pattern over the right upper abdomen)

Fluid Overload:

• Peripheral edema

Note: edema in ascites due to liver or heart disease is usually confined to the lower extremities only; if present also in upper extremities and hands, consider renal disease and nephrotic syndrome.

• Jugular venous distension (see JVP below)
• Pulmonary crackles (suspect CHF)
• Cardiac S3
• Positive hepatojugular reflux (link to neck veins module associated examination segment for description of exam maneuver)

Jugular venous pressure (JVP)

• When elevated, suspect right-sided heart failure
• If high JVP, also examine jugular waveforms further for constrictive pericarditis and check pulsus paradox

Lymphadenopathy; other signs of malignancy

Consider signs of other uncommon etiologies of ascites:

• Hypothyroidism
• Thyroid may be enlarged; skin dry with brittle hair; tongue enlarged (macroglossia), peri-orbital edema, delayed peripheral deep tendon reflexes (delay most prominent in return phase of reflex exam)
• Hemochromatosis
• Skin grayish or bronze and appears dirty
• Degenerative arthritis of extremities (usually hands and fingers, especially affected are PIPs of the middle and ring fingers)
• Wilson's disease (generally always presents before age 50)
• Eye: Kayser-Fleisher ring: brownish-green ring near limbus edge of iris - represents copper deposition in Descemet's membrane (has high sensitivity and specificity, although may need slit lamp to see)
• Funduscopic: "hyaloid" or colloid bodies - getanitous appearance on edge of disc that obscures the disc border (mimics papilledema); can give pt visual filed defects
• Nails: bluish discoloration of the lunula (termed azure lunule; not specific)

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