Palpation is often difficult with massive ascites, and ballottement of overlying fluid may be the only method of palpating the liver or spleen. A slightly enlarged spleen in association with ascites may be the only evidence of an occult cirrhosis. When there is evidence of portal hypertension, a soft liver suggests that obstruction to portal flow is extrahepatic; a firm liver suggests cirrhosis as the likely cause of the portal hypertension. A very hard or nodular liver is a clue that the liver is infiltrated with tumor, and when accompanied by ascites, it suggests that the latter is due. | Chapter 044. Abdominal Swelling and Ascites Part 2 Palpation is often difficult with massive ascites and ballottement of overlying fluid may be the only method of palpating the liver or spleen. A slightly enlarged spleen in association with ascites may be the only evidence of an occult cirrhosis. When there is evidence of portal hypertension a soft liver suggests that obstruction to portal flow is extrahepatic a firm liver suggests cirrhosis as the likely cause of the portal hypertension. A very hard or nodular liver is a clue that the liver is infiltrated with tumor and when accompanied by ascites it suggests that the latter is due to peritoneal seeding. The presence of a hard periumbilical nodule Sister Mary Joseph s nodule suggests metastatic disease from a pelvic or gastrointestinal primary tumor. A pulsatile liver and ascites may be found in tricuspid insufficiency. An attempt should be made to determine whether a mass is solid or cystic smooth or irregular and whether it moves with respiration. The liver spleen and gallbladder should descend with respiration unless they are fixed by adhesions or extension of tumor beyond the organ. A fixed mass not descending with respiration may indicate that it is retroperitoneal. Tenderness especially if localized may indicate an inflammatory process such as an abscess it also may be due to stretching of the visceral peritoneum or tumor necrosis. Rectal and pelvic examinations are mandatory they may reveal otherwise undetected masses due to tumor or infection. Radiographic and laboratory examinations are essential for confirming or extending the impressions gained on physical examination. Upright and recumbent films of the abdomen may demonstrate the dilated loops of intestine with fluid levels characteristic of intestinal obstruction or the diffuse abdominal haziness and loss of psoas margins suggestive of ascites. Ultrasonography is often of value in detecting ascites determining the presence of a mass or evaluating the
