A patient presented with massive abdominal distension. On examination, a fluid thrill was present. List three clinical diagnoses, which may produce these findings

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College Answer

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Candidates listing 3 correct differentials for a fluid thrill (see a-c below) or providing 3 conditions which may result in massive ascites (see d-f below) were awarded  full marks.

a)  Massive ascites
b)  Massive ovarian cyst
c)  Pregnancy with hydramnios

d)  Severe liver disease
e)  Budd-Chiari syndrome
f)   Severe right heart failure or pericardial constriction

g)  Abdominal malignancy.

Discussion

This question asks for a fairly random detail from Talley and O'Connor.

The "fluid thrill" is one of the tests for ascites; however it will be positive in any condition where a major part of the abdomen is taken up by a big lake of sloshing fluid. Essentially, it consists of somebody (possibly the patient) pressing down on the middle of their abdomen, and the physician percussing one side while feeling for the percussion wave in the other side. A big sloshy lake of fluid will allow the percussion wave to transmit across, whereas bowel gas or stool will transmit nothing.

This generally held to be pretty unreliable sign of ascites, as it requires the ascites to be massive, and under tension.

In either case, the college was fairly non-specific in their expected answer. They would have been happy to hear several different explanations for abdominal fluid (cysts of all sorts, ascites or massive hydramnios are all valid causes). They were equally happy about three different reasons for massive ascites (which leaves the answer pretty well open to any suggestion.. Budd-Chiari? Liver cirrhosis? Severe right heart failure?).

References

References

A good description of the fluid thrill test can be found at the website of the University of California, San Diego.