assessment of abdominal ultrasound findings in sudanese...
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The National Ribat University
Faculty of Graduate Studies & Scientific Research
Assessment of Abdominal Ultrasound Findings in
Sudanese Patients with Pathologies Associated
Ascites
A Thesis Submitted for Partial Fulfillment Required
for the MSc in Medical Diagnostic Ultrasound
By: Mohemed Edries Elmehana Abbass
Supervisor :Dr. Kamal Eldin Elbadawi Babiker
2017
I
اآليـــة
هللا الرحمن الرحيمبسم
ٹ ٹ
ی وئ وئ وئ وئ وئ وئ وئ وئ وئ وئ وئوئوئ وئچ
صدق هللا العظيم چ
﴾٨٥﴿اإلسراء
II
Acknowledgement
In the name of Allah the most beneficent and most merciful
My study could have not seen the bright
without effective supervision of my keen
supervisor
Dr. Kamal Eldin Elbadawi Babiker
It give me great pleasure to express my
gratitude to him.
My thanks extended to any one helps me for
their great help.
III
Dedication
To my mother and soul of my father whom had taught
me fundamentals of knowledge.
To my friends unwavering support and
encouragement.
To my teachers, sisters and brothers
I dedicated this work
IV
Abstract
This was cross sectional study conducted in Khartoum state in different hospital,
Ribat University and Medical Corps hospitals. The study carried out from august
2016 to January 2017.
The problem of the study was lack of studies regarding to assess of
ultrasound finding in pathologies associated of ascites in Sudanese patients.
The study aimed to assess of ultrasound finding of pathologies associated
of ascites.
The data was collected from seventy patients classified and analyzed by using
the Statistical Package for Social Sciences (SPSS).
The study found that the males 45 (62%) were more affected than females
25 (38%). The more affected patients with pathologies associated with ascites
was higher in age group between (50_59) years old.
The majority of patients 62 (88%) had pathology with symptomatic ascites
where asymptomatic only found in 8 (12%).
Also the study showed that the majority 39 (56%) of cases had severe
ascites, the mild 16 (22%) and moderate 15 (21%) of cases.
The most common causes of ascites were portal hypertension and liver diseases
which represent (63%) of all cases.
The study concluded that the ultrasound is best motility of evaluation of
causesofpathologies associated with ascites and assessmentof their degree and
types.
The study recommended that further studies with large sample size must be
done.
V
ةالدراسمستخلص
هذه دراسة وصفيه مقطعيهتمت في عدد من مستشفيات والية الخرطوم، في مستشفى الرباط الجامعي
.2017إلى يناير 2016أغسطس الفترة منوأجريت في ،الطبيوالسالح
التي تتعلق بتقييم اكتشاف الموجات فوق الصوتية في عدد الدراسات في قلهالبحث مشكلةتكمن
السودانيين.في المرضى ألبطنيتراكم السوائل في التجويف األمراضالمرتبطةب
ألبطني تراكم السوائل في التجويف نتيجة الموجات فوق الصوتيةلألمراضالمرتبطةبتقييم الدراسةإلىهدفت
.دانيينفي المرضى السو
تم جمع البيانات من سبعين مريضا تم تصنيفهم وتحليلهم باستخدام الحزمة اإلحصائية للعلوم االجتماعية .
%( وكانت الفئة 38بنسبة )25٪( كانوا أكثر تأثرا من اإلناث 62) 45وجدت الدراسة إلى أن الذكور
٪( 88) 62( سنةوكانت معظم المرضى 59_50بالمرض بين ) تأثراالعمرية األكثر
حاالت 8كانوا وإعراضوعالمات المرض بينما المرضى الذين ليس لديهم عالمات عراضأمصحوبةب
٪(.12بنسبة )
سوائل بكميات كبيره، في حين أن راكمها تدي٪( من الحاالت ل56) 39كما أظهرت الدراسة أن الغالبية
(.٪12) وكانت بنسبة 15٪(والمعتدلة 22) 16كانت بسيطة الالكميات
هي ارتفاع ألبطنيالسوائل في التجويف راكملتالمسببة وأيضا وجدت الدراسة أن أكثر األمراض شيوعا
٪( من جميع الحاالت.63وأمراض الكبد التي تمثل ) ألبابيضغط الدم
السوائل األمراض المرتبطة بتراكمئل لتقييم الوسا أفضلهي الصوتيةالموجات فوق الدراسةإليأنوخلصت
ودرجاته. أنواعهوتحديد ألبطنيفي التجويف
.أفضلنتائج لحصول علىبيره لدراسات ذات عينات كعمل لضرورة وأوصت الدراسة
VI
List of Abbreviations
AAT Alanine Amino Transferse
ARF Acute Renal Failure
CHF Congestive Heart failure
CRF Chronic Renal Failure
CSF Cerbro Spinal Fluid
CT Computerize Tomography
HCC Hepato Cellular Carcinoma
IVC Inferior Vena Cava
NM Nuclear Medicine
PID Pelvic Inflammatory Disease
PSS Porto Systemic Shunt
RCC Renal Cell Carcinoma
RUQ Right Upper Quadrant
SAAG Serum Ascites Albumin Gradient
SBP Spontaneous Bacterial Peritonitis
TB: Tuberculosis
TGC Time Gain Compensator
TJIH Trans Jugular Intra Hepatic
US Ultra Sound
VII
List of figures
Page
No.
Title Fig
No. 5 Anatomy image shows a severe case of ascites 2.1
8 US image shows portal hypertension 2.2
11 US image shows congestive heart failure 2.3
13 US image shows renal cell carcinoma 2.4
18 US image shows chronic pancreatitis 2.5
27 Shows frequency distribution of patientsages. 4.1
28 Shows the correlation between gender and gender in patients with ascites.
4.2
29 Shows frequency distribution of ascites according to
symptoms.
4.3
30 Shows frequency distribution of causes of ascites. 4.4
31 Shows frequency distribution of the degree of ascites 4.5
33 Shows the correlation between asymptomatic ascites
and their degrees.
4.6
33 Shows the correlation between symptomatic ascites and their degrees.
4.7
VIII
List of Tables
Page
No.
Title Table
No. 27 Shows frequency distribution of patientsages. 4.1
28 Shows the correlation between gender and fender in patients with ascites.
4.2
29 Shows frequency distribution of ascites according
to symptoms.
4.3
30 Shows Chi-Square Tests of the correlation between gender and age in patients with ascites.
4.4
31 Shows frequency distribution of ascites according to
symptoms.
4.5
32 Showed the correlation between signs, symptoms and
their degree.
4.6
32 Showed Chi-Square test of the correlation between signs, symptoms and their degree.
4.7
IX
List of contents
Page
No.
Title
I Alaya
II Acknowledgement
III Dedication
IV Abstract (English)
V Abstract (Arabic)
VI List of abbreviations
VII List of figures
VIII List of tables
IX-XI List of contents
Chapter One: Introduction & Objectives
1 Introduction. 1.1.
2 Problem of the study 1.2.
3 Objectives 1.3.
3 General objectives 1.3.1.
3 Specific objectives 1.3.2.
Chapter Two : Literature Review
4 Ascites 2.1.
4 Clinical considerations 2.2.
4 Symptom of ascites 2.2.1
5 Sign of ascites 2.2.2.
X
5-6 Causes of ascites according to laboratory investigation
2.3.
6 Possible amount and complication of ascites 2.4.
6-7 Diagnosis of ascites 2.5.
7 Pathology related to ascites 2.6.
7-12 Hepatic pathologies associated with ascites 2.6.1.
12-13 Heart pathologies associated with ascites 2.6.2.
13-17 Renal pathology associated with ascites 2.6.3.
17-19 Infectious disease 2.6.4.
19 Treatment 2.7.
19-21 Methods ofascitesassessment 2.8.
21-22 Previous studies 2.9.
Chapter Three : Material & Methods
23 Study design 3.1.
23 Study area 3.2.
23 Study duration 3.3.
23 Study population 3.4.
23 Inclusion criteria 3.4.1.
23 Exclusion criteria 3.4.2.
23 Study variables 3.5.
24 Sampling of the study(type and size). 3.6.
24 Instrumentations 3.7.
24 Data analysis 3.8.
XI
24-25 Abdominal ultrasound technique 3.9.
26 Ethical considerations 3.10.
Chapter Four: Results
27-33 Results. 4.1.
Chapter Five: Discussion, Conclusion and Recommendations
34-35 Discussion 5.1.
36 Conclusion 5.2.
37 Recommendations 5.3.
38-39 References.
Appendix:
Images
Data collection sheet.
XII
Chapter One
Introduction
1
1.1. Introduction:
US is the dominant first line investigation for an enormous variety of abdominal
symptoms because it is noninvasive and comparatively accessible nature and its
benefits to patients outweigh the risks. Also the Doppler US is an integral part
of the examination because many pathological processes in the abdomen affect
the hemodynamic of relevant organs (1).
The peritoneum is a thin membrane that lines the wall of the abdominopelvic
cavity which forms by two layers; the outer layer is the parietal peritoneum
attached to abdominal walls and pelvic walls. The inner layer; the visceral
peritoneum, is wrapped around the visceral organs, located inside the
intraperitoneal space for protection. It is thinner than the parietal peritoneum (2).
Peritoneum consists of connections connects viscera to each other and to
abdominal and pelvic walls. These connections of peritoneum are folds called
ligaments, mesenteric, mescolons and omenta and they contain fat, nerves, blood
vessels, lymph vessels and sometimes bile ducts,the peritoneum classifies the
organs into three types: intraperitoneal, retroperitoneal and extra peritoneal. The
mesentery is a double layer of visceral peritoneal that attaches to the
gastrointestinal tract. There are often blood vessels, nerves and other structures
between these layers. The space between these two layers is technically outside
of the peritoneal sac, and thus not in the peritoneal cavity. The potential space
between these two layers is the peritoneal cavity; is filled with small amount
(less than 100 ml) of the slippery serous fluid that allows the two layers to slide
freely over each other(2).
Ascites is a term given to the presence of free fluid in the peritoneal cavity
when exceeding the amount of 100 ml and there are two type of ascites;
2
transudative ascites: its fluid contains little or no protein and caused by increase
intravascular pressure; exudative ascites; its fluid contain debris and caused by
decrease vascular permeability resulting of increasing the levels of plasma
entering the interstitial areas(4).
US rapidly becoming initial imaging study for detection of free fluid inside the
peritoneum cavity. Despite the normal serous fluid within peritoneal cavity is
not evident in sonogram. Simple ascites (transudate), is anechoic but septation
and debris are found in (exudates) one and appears sonographically as a fluid
with low level echoes. Also US is the best choice worldwide for the detection of
intra-abdominal injury (IAI), in view of hemorrhage, old hematomas and
abscesses (3).
Transudative ascites is most commonly caused by alcoholic cirrhosis and
organ failure but oxidative ascites is associated with infection and malignancy.
Although this diagnosis based on US solely but is often not possible, however
lab test results, clinical history and fine needle aspiration are helpful in definitive
diagnosis. The US helps in choice of appropriate treatment (Conservative
percutaneous drainage or surgical intervention)(3).
1.2. Problem of the study:
The lack of similar local studies regarding to assessmentof abdominal
ultrasound finding of pathologies associated ascites in Sudanese patients.
1.3. Objectives:
3
1.3.1 General objective:
To assessment the abdominal ultrasound findings in Sudanesepatients with
pathologies associated ascites by using ultrasound.
1.3.2 Specific objective:
1- To assess the causes of ascites by using ultrasound.
2-To determine the accuracy of ultrasound in detecting the definitive diagnosis
of abdominal ultrasound findings in diseases associated with ascites.
3- To correlate between the signs and symptoms of acites with their degrees.
4
Chapter Two
Literature Review
4
2.1 Ascites:
Is the presence of free fluid in the peritoneal cavity and there are two
types; Transudative ascites: its cause by an increase in intra vascular pressure
due to heart, renal or liver failure. This fluid contains little or no protein and is
usually an echoic, liver disfunction is common cause.
Exudative ascites: It cause by decrease in vascular permeability resulting in
increased level of plasma entering the interstitial areas. This type is associated
with infections and malignancy exudative ascites may contain low level echoes
secondary to cellular material.
Sonographically:Simple ascites or transudate is anechoic no septations or
floating. Debris is usually found in exudates or in ascites complicated by
hemorrhage or infection. Massive ascites displaced the liver spleen and bowel
toward the center of the abdomen. The bowel itself may be appears as echogenic
structure at the periphery of the mesentery. Massive ascites can increase intra-
abdominal pressure resulting in slit like narrowing of the upper IVC when the
patient is supine. The IVC returns to normal when the patient sits or lies on left
lateral decubitus position. This appearance should not be mistaken for
anastemosis or pressure from liver lesion.Loculated ascites as an isolated finding
can appear similar to lymphocele, cyst, abscess or neoplasm(5).
2.2. Clinical considerations:
2.2.1. Symptom of ascites:
Small amount of ascites is a symptomatic, large amount of ascites causes
abdominal distention, pressure and discomfort, respiratory distress, anorexia,
nausea, early satiety, heart burn and flank pain(6).
5
2.2.2. Sign of ascites:
Umbilicus may be evert, bulging flank with patient supine, tympanic at the top
of the abdomen with the patient supine, flank shift when the patient turned on
side, shifting dullness test and buddle sign. There may be other signs and
symptoms according to the main cause: fatigue, leg swelling,
bruising,gyencomastia, hematemesis, weight loss, wheezing and mental change
(encephalopathy) (6).Fig (2.1).
Fig (2.1): Shows a severe abdominal ascites.(10).
2.3. Causes of ascites according to laboratory investigation:
2.3.1 Causes of highserum-ascites albumin gradient(SAAG):
Cirrhosis alcoholic, viral cryptogenic, schistosomiasis, portal
hypertension, nephritic syndrome, congestive heart failure, constrictive
pericarditis, hepatic venous occlusion,Budd-Chiari syndrome, veino occlusive
disease (IVC), peritoneal dialysis (SCF), secondary to ventriculoperitoneal
diversionary shunt and Kwashiorkor child hood protein energy malnutrition(8).
6
2.3.2 Causes of low Serum-ascites albumin gradient (SAAG):
Malignancy, primary peritoneal carcinomatosis, RCC, HCC, ovarian cell
carcinoma, infection, tuberculosis, spontaneous bacterial peritonitis,
pancreatitis, serositis, PID, rupture ectopic pregnancy, post-operative state and
hereditary (angioedema) (6).
2.3.3 Other cause of free fluid in the peritoneum:
Meig's syndrome, vasculitis, hypothyrodism, Crohn's disease, ovarian
condition; ovarian fibroma, rupture ovarian cyst, ovarian torsion, lymphatic
obstruction, biliaryperforation, urinary tract perforation, bowel perforation,
trauma (liver, spleen and pancreas) and bleeding diathesis(6).
2.4. Possible amount and complication of ascites:
Ascites can accumulate as a transudate or exudates in amounts less than
100 ml are possible. Possible complications are hepatorenal syndrome due to
disruption of the renal blood flow, spontaneous bacterial peritonitis (SBP) due
to decrease antibacterial factors in ascites,additional fluid retention by the
kidneys due to stimulators effect on blood pressure hormones, aldosterone,
sympathetic nervous system is more activated and increase of rennin production
and thrombosis in the portal vein and splenic vein (7).
2.5. Diagnosis of ascites:
Its includes routine complete blood count (CBC), basic metabolic profile,
liver enzymes, and coagulation should be performed. Most experts recommend
a diagnostic paracentesis be performed if the ascites is new or if the patient with
ascites is being admitted to the hospital. The fluid is then reviewed for its gross
appearance, protein level, albumin, and cell counts (red and white). Additional
7
tests will be performed if indicated such as microbiological culture, Gram stain
and cytopathology.
The serum-ascites albumin gradient (SAAG) is probably a better
discriminant than older measures (transudate versus exudate) for the causes of
ascites. A high gradient (> 1.1 g/dL) indicates the ascites is due to portal
hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal
hypertensive as a cause.
Ultrasound investigation is often performed prior to attempts to remove
fluid from the abdomen. (7).
2.6. Pathology related to ascites:
2.6.1 Hepatic pathologies associated with ascites:
2.6.1.1 Portal hypertension:
It is a characterized by elevation of the portal pressure which is normally
very low pressure. It is either occur from increase in total portal venous flow
or from an increase in resistance in the portal system (prehepatic, intrahepatic
and post hepatic) its common causes includes; thrombosis, obstruction due to
tumor, diverticulitis, inflammatory bowel disease, coagulopathy, sepsis,
pyelophelebitis, omphalitis, appendicitis, trauma, cirrhosis, schistosmiasis,
sarcoidosis,congenital hepatic fibrosis, hepatitis, alcoholic, Budd-Chiari
syndrome and HCC; the patient present with ascites; splenomegaly, jaundice,
hematemesis are signs and symptoms of hepatic failure; the
sonographicfindings include; an enlarge portal vein > 13.0 mm and its caliber
unchanged with respiration, enlarge splenic and superior mesenteric veins >10.0
mm, periportal fibrosis (echogenic) wall and the portal vein becomes comma
shaped. Splenomegallyand recanalization of umbilical and paraumbilical, vein
8
bulls eye appearance ofligamontumteres. Multiple tubular structures (caput
medusa) representing collaterals of umbilicus vein(8).Fig (2.2).
Fig (2.2): Shows portal hypertension with recanalized umbilical
vein.(11).
2.6.1.2. Budd-Chiri syndrome:
It is characterized by obstruction of hepatic venous outflow due to
obstruction of hepatic portion of IVC. The cause may be due to thrombosis,
veinoocclusive disease, neoplasm, tumor or unknown etiology. But abscess, oral
contraceptives, radiation of the liver, pregnancy, leukemia and others may be
associated; It has three types; type I obstruction of IVC with or without of
hepatic vein; type II obstruction of hepatic vein with or without IVC; type III
occlusion of the small centrilobular veins (liver function test is abnormal);
sonographically the caudate lobe enlarged or may be normal and hypoechoic
than the liver, absent of flow or narrowing of intra hepatic portion of IVC,
absent, reversed, turbulent flow of IVC or hepatic veins on doppler studies,
echogenic and thick walls of hepatic veins, shunting between hepatic circulation
and ascites (8).
9
2.6.1.3 Cirrhosis:
Is a diffuse process characterized by cell death, fibrosis and nodular
regeneration.The most common causesare alcohol, hepatitis, glycogen storage
disease and parasite. Cardiac cirrhosis occurs due to heart failure; billiary
cirrhosis occurs due to bile duct obstruction and cirrhosis in neonates cause by
billiary atresia, 60% of the patients have sign and symptoms like jaundice,
hepatomegally, pain and ascites. Advanced type characterized by shrunken
nodular liver and compromised in hepatic circulation resulting in portal
hypertension and increase risk of HCC as well as Budd-Chiri syndrome. In the
laboratory test AST are associated with early cirrhosis. ALT elevates moderately
in late stage with increase prothrombintime and decrease serum albumin level
(8).
The Sonographic finding; abdominal ascites frequently associated with
cirrhosis. Liver normal or enlarge in early stage and shrunk in late stage. The
Liver contour may be irregular with knobby protrusions and indentations.
Fibrosis increases liver echogenicity and degeneration make liver contains
hypoechoic areas. Intrahepatic vessles may be visualized. Portal hypertension
and associated finding will be apparent.The echogenic wall of the portal vein
poorly delineated. Attenuation of the sound beam with poor visualization of the
liver in the far field. In spite of that the fissures become well visualized. The
right lobe usually small and the left and cuadate lobes may be enlarged so it must
to increase TGC or power to permit good visualization(9).
2.6.1.4. Acute viral hepatitis:
10
It is a viral infection of the liver cells associated with jaundice, anorexia,
nausea and fatigue. The liver often enlarges with increase in AST and ALT
laboratory test levels due to necrosis of an acute nature; sonographic findings
include; hepatomegaly is the most common manifestation. Normal hepatic
echogenicity, uncommonly hydropic cloudy swelling of the liver cells and
increase extracellular fluid brightness of collagenous wall of portal vein in
comparison with hypoechoicparenchyma. Thicken of gall bladder wall
associated with ascites in severe cases(9).
2.6.1.5. Chronic hepatitis:
Hepatitis B represents a very different and much more dangerous
situation. May be asymptomatic for a year while the liver is widely destroying,
then it leads to death through cirrhosis or cancer. The disease is incurable, then
it cannot be stopped and the diagnosis is complete when there is a hepatic
inflammation for at least 3 to 6 month. Pt present with high ALT and AST;
sonographically the liver has a coarse pattern, decrease in brightness of the portal
triad due to periportal fibrosis, portal hypertension with it is associated causative
finding with ascites (9).
2.6.1.6. Metastases:
The liver is the most sites of metastasis from all types of tumor due to blood
supply. Metastatic neuroblastoma is the most common on children. In adults
common metastatic from lung, colon, pancreas, breast and stomach. There is no
definite correlation between sonograhicapearance of metastatic lesion and the
primary site. Patient present with hepatomegally, abdominal distension from
ascites, weight loss and abnormal liver function tests; sonographically the
metastatsis are always multifocal with increase or decrease echogenicity,various
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size and shape and lesion poorly defined margins. Echogenic center surrounded
by a hypoechoic rim which called target or bull's eye appearance, heterogeneous
echo texture of the liver, masses with shadowing due to calcification, liver
contour may be normal or lobulated,billiary tract dilatation occur from
compression of the bile ducts by the tumor and ascites usually presents(9).
2.6.1.7 Hematoma:
Traumatic injuries of the liver are fairly common and hematomas are
divided into three; intrahepatic, subcapsular and hepatic laceration with ruptured
capsule. Blunt or penetrating trauma is the most common cause of injury to the
liver. Patient present with RUQ pain, abdominal distension, shock, elevated liver
enzymes and bilirubin level as well as a decrease in hematocrit and leukocytosis;
sonographicfinding depends on the age and location of hematoma. Round or
oval echogenic mass with well define margins are seen. In late
stagebecomehypoechoic or anechoic with poorly delineated margins,
septationandhypo echoic degeneration (1-4 week). Subcapsularhematoma is
curvilinear or lenticular shape. Ascites with or without low level echoes. There
may be associated trauma in the kidneys and spleen (9).
2.6.1.8 Schistosomiasis:
Is one of the most common parasitic infections in humans estimated to
affect 200 million people worldwide. It is transmitted by fresh water snails from
tropical areas. The larvaes penetrate the skin and migrate into the peripheral
vessles, traverse the lungs and settle in the portal venous system. After
maturation, female produce hundreds of eggs daily then the body produce
granulomas and fibrosis around the eggs. This result in occlusion of terminal
portal vein branches with sub sequent portal hypertension; sonographic findings;
12
splenomegally, varices, ascites, there are echogenic, widened portal vessels in
the region of portahepatis. Initially the liver size is enlarging, then after
periportal fibrosis the liver contracted(8).
2.6.2. Heart pathologies associated with asites:
2.6.2.1 Congestive heart failure (CHF):
Is a condition in which the heart functions as a pump is inadequate to meet
the body needs. A poor blood supply resulting from CHF may cause the body's
organ system to fail, leading to weakened heart muscle and fluid accumulation
in the lungs and body tissue. There are many diseases that can impair pumping
efficiency and symptoms of CHF include; thefatigue, diminish exercise
capacity, shortness of breath and swelling. The disease then develops marked
dilatation of intrahepatic veins with significant liver function test abnormalities;
sonographicaly liver texture and echogenicity is usually normal. Number of
vessels visualized with the liver is much increased. Diameter and length of the
vessels is greater than normal and don't show aphasic collapse with respiration.
IVC will be seen throughout its entire length.Thrombus formation is common
(Low level echos within IVC) ascites is common (8).Fig (2.3).
13
Fig (2.3): Shows congestive heart failure, both ascites and pleural effusion
are present.(12)
2.6.3 Renal pathology associated with ascites:
2.6.3.1 Renal cell carcinoma:
Have other name like hypernephroma, renal adenocarcinoma and
Granitz's tumor. It is the most common malignant tumor with high mortality rate,
males above 50 years old have more incidence. The tumor originates in the
tubular epithelial cells and then spread out to the lung, liver, adrenal gland and
contra lateral kidney. They are usually unilateral and clinically silent until they
become large and have complication like hypertension, nonfunctional kidney,
obstruction of collection system or renal vein and thrombosis; sonographicalyan
irregular lobulated solid mass with variable echogenicity and may be
homogeneous or heterogeneous. Tumor margin may be indistinct from normal
parenchyma and variable acoustic enhancement may be present. Anechoic areas
due to hydronephrosis and within the lesion are due to hemorrhage or necrosis.
The mass mimic multi loculated cyst and cause contour deformity. Thrombus
tumor may found in the renal vein and IVC as medium level echoes with enlarge
vessel and doppler studies aid in diagnosis(8).
2.6.3.2 Wilm'sTumor:
It also called nephroblastoma or embryonic cell carcinoma, it rapidly
growing tumor affects male more frequently and almost exclusively in children
under the age of 5 y, it is mostly interarenal and distorts the collecting
system.This condition may associate with other congenital abnormalities and
metastasis invades lungs, lymph node, liver and bone. The patient coming with
14
palpable mass, hypertention, hematuria, weight loss and anemia;
sonographicfindingcommonly are large, solid, well-circumscribed renal mass
with echogenicity less than the kidney and variable to more than the liver and
may be homogeneous or not. The mass has sharp margin with hypoechoic or
hyperechoic rim, and calcification may be present with shadowing. Other
findings may be present like renal vein thrombosis and ascites(8).
2.6.3.3 Renal metastases:
Focal or diffuse lesion may infiltrate the kidney as metastasis from the
lung, breast, stomach and contralateralkidney, but renal metastases occur in
patients with widely disseminated malignancy. Clinically the patient may be
asymptomatic or have renal enlargement, pain, hematouria and decreased renal
function; sonographicfinding in kidney with focal or multiple masses of variable
echogenicity. The echogenicity vary depend on the primary cause of the tumor
for example lymphoma tends to have multiple focal lesion and the leukemia
tends to produce hyperechoic focal lesions(8).Fig (2.4).
Fig (2.4): Shows transitional cell carcinoma in the upper pole of the
Rtkidney. (13).
15
2.6.3.4 Acute renal failure (ARF):
Renal failure considered acute if it develops over days or weeks, due to
insufficient renal perfusion (pre-renal cause), intrinsic renal disease (renal cause)
or obstructive uropathy. The main purpose of US study is to exclude
hydronephrosis. Sonographicfinding: if the cause is tubular necrosis due to
ischemia from trauma, hypotension, dehydration …ect the kidneys may normal
or enlarge with prominent hypoechoic pyramids. If the cause is
glomerulonephritis both kidneys are affected with variable size and echopattern
of the cortex is altered with medullar sparing and may be normal hypo or hyper
echoic, with treatment the kidneys revert to normal if the cause is interstitial
nephritis due to hypersensitivity reaction drug or others. The size of the kidney
becomes enlarge and hyperchoic(8).
2.6.3.5 Chronic Renal Failure:
It considers when the failure developed over spans of months or years. The
most common causes are diabetes mellitus, the other causes include vascular
disease, gout, glomerulonephritis, chronic pyelonephritis; sonogrphicaly there is
initial renal enlargement but then occurs reduction in size and increase
echogenicity. The corticomedullaryjunction is preserved and in the late stage the
medulla is not identified. Thrombosis and ascites may be present(8).
2.6.3.6 Nephrotic syndrome:
It is a nonspecific disorder in which kidneys are damaged, causing to leak
large amounts of protein from blood into urine. Kidneys affected by nephritic
syndrome have small pores in the body sites, large enough to permit proteinuria
but large enough to allow cells through. By contrast RBCs pass through the pores
16
causing hematuria. Is common among 2-6 years old; sonographicalythe most
common seeing is excess fluid in the body due to serum hypoalbminemia, the
fluid accumulates within interstitial tissue causing ascites, pleural effusion,
general edema and swelling. The common causes are
glomerulosclerosis,sarcoidosis, hepatitis B, C and drugs(8).
2.6.3.7 Renal dialysis:
It cleanses the waste products in the body by using filter system, there are
two types; Hemodialysis. Peritoneal dialysis; Peritoneal dialysis is sometimes
associated with ascites. It uses the lining of the abdominal cavity as dialysis filter
to rid the body of waste and balance electrolyte levels by using a catheter(8).
2.6.3.8 Renal Transplant:
The transplant kidney is usually placed retroperitoneal in the iliac fossa
and the vessels are anastomosis to internal and external iliac vessles. In children
transplanted kidney is intra abdominally and vessels anastomosis to aorta and
IVC; sonographicalythe renal allograft is enlarging after transplant with central
renal sinus is highly echogenic. The most peripheral portion is hypoechoic and
the medulla is hypoechoic triangular shape. Arcuate vessels can be seen at
corticomedullaryjunction and be quite distinct. There are some conditions
associated with renal transplant like;Urinoma; lymphocele; hematoma; abscess;
hydronephrosis and renal artery thrombosis (9).
2.6.4 Infectiousdisease:
2.6.4.1 Acute pancreatitis:
Acute inflammation of the pancreas varies in severity from mild
(edematous) pancreatitis to necrotizing or hemorrhagic pancreatitis. The
pancreatitis which causes ascites, is type two in which the release of proteolytic
17
enzymes (protease lipase) produces destructive changes in the pancreas and
peripancreatic tissue. Alcohol, gallstones, penetrating peptic ulcers are
peridisposing factor, patient present with severe RUQ pain, vomiting fever, the
patient may present in shock.Sonographic finding;pancreas may be normal or
enlarge particularly in the head and tail. The echogenictiy depends on the
severity of the disease. But it may be markedly hypoechoic, may be hyperechoic
and heterogeneous, the pancreatic margin is regular and ill defined.An echoic
pseudocyst may present on the lesser sac or anywhere in retroperitoneum.
Ascites appear in every severe case (9).
2.6.4.2 Chronic pancreatitis:
Result from repeated or prolonged acute pancreatitis, hyper
parathyroidism, cysticfibrosis, malignancy. Complications of chronic
pancreatitis include malabsorbtion syndrome, diabetes mellitus, portal
hypertension or thrombosis. Patient has severe RUQ pain, anorexia and diabetes
mellitus. Sonographic finding: pancreas may be normal, small or enlarge.
Enlargement may focal or diffuse and may mimic carcinoma of pancreas.
Echogenicity may be normal, hypo or hyper. And heterogeneous appearance is
due to necrosis, fibrosis due to the inflammation or may be there is calcification
with acoustic shadowing. Pancreatic duct is present with dilatation and
irregularity. Anechoic mass represents pseudocyst may found on the lesser sac.
18
Other site of ascites may be present and extra hepatic billiary tract is
dilated(9).Fig (2.5).
Fig(2.5): US image shows chronic pancreatitis.(14).
2.6.4.3 Tuberculosis:
Is a chronic bacterial infection with pulmonary involvement is the most
frequent location. TB maycause gaseous, nodules and adhesions;
sonographicallyuniform and circumferential wall thickening of the cecum and
terminal ileum, enlarge mesenteric lymph nodes, ulceration are visible, pseudo-
kidney sign into subhepatic region due to invovelement of the ileum and cecum
in this area the ascites fluid contains fine, freely mobile septa. Affected liver
appears with multiple small granulomas giving "bright" pattern of the liver. On
spleen there are multiple hypoechoic nodules without splenomegally(9).
2.7. Treatment:
19
Ascites can be treats conservatively, or by percutaneous drainage or
surgically. It is generally treated simultaneously while an underlying etiology is
sought in order to prevent complication area to relief the symptoms as well as
prevent further progression.Hospitalization is necessary in patient with severe
ascites(9).
2.8. Methods of ascites assessment:
2.8.1. Plain radiograph:
Detection of intraperitoneal fluid on a plain radiograph requires at least
500 mL to be present.
Plain film findings of ascites include:
*Diffusely increased density of the abdomen
* Poor definition of the soft tissue shadows, such as the psoas muscles, liver
and spleen
* Medial displacement of bowel and solid viscera (away from properitoneal fat
stripe)
* Bulging of the flanks
* Increased separation of small bowel loops
2.8.2. Ultrasound:
Classification:
20
Ascites exists in three grades: grade 1(mild): Only visible on US and CT
in Morrson's pouches; grade 2 (moderate) detectable with flank bulging and
shifting dullness, Morrson's pouches, splenorenal and gutters; grade 3 (severe)
directly visible, confirmed with fluid thrill in all over the abdomen (7).
Assessment:
Various methods have been used in different clinical & practical and
research studies. Each method is liable to errors & variations and all of which
depends on experience, expertise of operators. There are some of methods; Semi
quantitative measure (subjective assessment): is generally not help clinically&
needs experience, expertise and is subject to significant operator variability. It is
classified by looking for the presence of fluid in five areas of the abdomen
namely right upper quadrantabdomen RUQ(perihepatic and Morrison's pouch),
left upper quadrantabdomen LUQ (perisplenic), right paracolic gutter, left
paracolic gutter and pelvis: fluid in 1 location (minimal ascites), fluid in 2
locations (mild ascites), fluid in 3 locations (moderate ascites), fluid in 4
locations (marked ascites) and fluid in 5 locations (massive ascites)(9). The
smallest fluid depth measured from the most superficial bowel loop to the
abdominal wall & the fluid volume is 5 L for depth measurement of 5 cm & for
every 1 cm increase in the measured depth, there is an average 1 L increase in
the volume. Smallest fluid depth (cm) X 1000 = volume (cc). The longest fluid
depth: Measure the maximal fluid depth (AP diameter)x100= volume in cc.
Depth of deepest pocket (cm) X 100 = volume (cc)(7).
21
2.8.3. CT:
CT is most sensitive to small amounts of fluid in the peritoneum
which collects preferentially in the dependent regions, such as Morison
pouch and the pelvis.
2.9. Previous studies:
In a study done by Najla Hussein Mohammed (2005-2006), studied (100)
patient in kingdom of Saudi Arabia in King Fahad and Alnasar Hospitals in
Medina Alhaya, Almalkia,Yanbu. The data collected from the diagnostic reports
of US. The study done to measure the sensitivity of US, classification of ascites
and differentiated between its two types. The Result showed that out of 100
patients there were 83% had liver cirrhosis, 3% had congestive heart disease,
4%, TB 4%, renal failure, 6% had other disease; 86% out of (100) had
transudative ascites.(8)
In study done by Esra Salah EldinAhmmed (2010-2011); studied 250 patients in
Omdurman Military Hospital, to evaluate the role of US in finding the incidence,
type and causes of ascites in Sudanese patients.Theresult showed thatthe male
were three times more affected than female, also the transudative type was more
common (75%) than the exudative one (25%)(9).
22
23
Chapter Three
Materials and Methods
23
3. Materials and Methods
3.1. Study design.
This is a cross sectional study.
3.2. Study area.
The study was conducted in Ribat University and Medical Corps Hospitals
at Radiology department.
3.3. Study duration.
The study carried out from August 2016 to January 2017.
3.4. Study population.
The study included 70 patients who were clinically complained from
ascites.
3.4.1. Inclusion criteria.
Any patientscomplaining of pathologies associated with ascites and their
ages ranged between (18-70) years.
3.4.2. Exclusion Criteria.
Any patient with pathologies without association of ascites and their ages
below 18 and above to 70.
3.5. Study variables.
Age, gender and pathologies associated with ascites.
24
3.6. Sampling of the study (Sample type and size).
70 Patient whom had been taken randomly either male or female and
their ages (18->70).
3.7. Instrumentation.
The abdominal US was done by using the Mendary US machine with
curvilinear probe (3.5 MHz) for adults.
3.8.Data Analysis.
Data were analyzed by using Statistical Package for Social Sciences
(SPSS) version 2010, and presented in tables and graphs.
3.9. Abdominal ultrasound technique.
Misinterpretations of ultrasound images is a significant risk in US
diagnosis because ultrasound is operator dependent the sonographer must have
proper training to maximize the diagnostic information and interpret image.
Sonographermust understand physiological and pathological changes then made
good relation between pathological and clinical information.Also knowledge of
the equipment must be good to avoid the artifacts and pitfalls of scanning. use
the highest frequency, increase the line density by reducing the frame rate and
reducing the sector angels as possible as.And make compensation between this
and the needed depth.Using tissue harmonics to reduce artifact and get higher to
and signal to noise ratio, especially in obese and gassy abdomens Restless or
breathiness patients will require a higher frame rate. Use the focal zone at
relevant depth.
25
Many pathological Processes in the abdomen affect the thermodynamics of
relevant organs the use ofdoppler US is an integral and essential part in
abdominal US. Choose the suitable transducers consider foot print, shape and
frequency, (curved array probe with 3.5 MHz) is suitable for most general
abdominal applications but modem transducers with broad band frequencies are
useful linear probes, endoprobes, intra operative probes and other designs are
needed for guideline biopsy and other invasive procedures. Other important
issue must be consider like time gain compensator, output power, body marker
and labeling functions.
Area of interest are completely evaluated in at least two scanning planes
(longitudinal and transverse) which is cold a combined survey. Full abdominal
surveys begin with aorta thenIVC. Liver and then rest of abdominal organs and
associated structures. A machine with good quality image is rich economy, the
images are taken after complete survey as documentation and this must be done
in logical sequence.
Patient comfort and the amount of transducer pressure on the skin is an
important consideration although more presses may make the patient
uncomfortable. Patient in abdominal US scanning is Prefer to be fasting put
ascites patient haven’t preparation required. Patient is scanning in Supine
Position and also decubitus either right lateral decubitus or left lateral decjjbjtu5
Scan may help to differentiate loculated and free fluid Collection We can use
the Posterior approach if needed. Patient scan in deep inspiration or protrusion
of abdominal wall if he or she is capable. Peritoneal cavities in the normal patient
are not routinely visualized.
26
3.10. Ethical Considerations.
During the study the patient's details had not be mentioned and verbal
consent was taken from them in keeping with the patient privacy, with approval
of authority of faculty of graduate studies, The National Ribat University.
27
Chapter Four
Results
27
4. Results:
Table (4.1): Shows frequency distribution of patients age.
Age Frequency Percent
18-29
30-39
40-49
50-59
60-69
>70
3
5
10
33
13
6
70
4.2%
7.1%
14.3%
47.1%
18.6%
8.6%
100%
Fig (4.1):Shows frequency distribution of patient age.
3 5
10
33
13
6
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
18-29 30-39 40-49 5059 60-69 >70
Ages group
28
Table (4.2): Shows frequency distribution of patients gender.
Gender Frequency Percent
Males 45 64.0%
Females 25 36.0%
Total 70 100%
Fig (4.2): Shows frequency distribution of patients gender.
0%
10%
20%
30%
40%
50%
60%
70%
Per
cen
t %
Gender of Patients
Males Females
45
25
29
Table (4.3): Shows frequency distribution of ascites according to symptoms.
Types of ascites Frequency Percent
Symptomatic 62 88.5%
Asymptomatic 8 11.5%
Total 70 100%
Fig (4.3): Showsfrequency distribution of ascites according to symptoms.
62
80%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Symptomatic Asymptomatic
Per
cen
t %
Types of Ascites
30
Table (4.4): Shows frequencydistribution of ascitescauses.
Cause Frequency Percent
Cirrhosis (PHT)
Hepatitis
HCC
CHF
Renal failure
Peritonitis
Total
47
2
6
9
4
2
70
67.1%
3%
8.5%
12.8%
6%
3%
100%
Fig (4.4): Shows frequencydistribution ofascitescauses.
47
26
9
43
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Cirrhosis &PHT
Hepatitis HCC CHF Renal failure Peritonitis
Causes of ascites
Pe
rce
nt
%
31
Table (4.5): Shows frequency distribution of the degree of ascites
Degree Frequency Percent
Mild
Moderate
Severe
16
15
39
22.8%
21.5%
56%
Total 70 100%
Fig (4.5): Showsfrequency distributionof the degree of ascites.
16 15
39
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Mild Moderate Severe
Per
cen
t %
Degree of Ascites
32
Table (4.6): Showed the correlation between signs, symptoms and their
degrees.
Table (4.7): Showed Chi-Square test of the correlation between signs,
symptoms and their degrees.
Symptomatic Asymptomatic
13.000 3.250 Chi-Square(a,b)
2 2 df
.002 .197 Asymp. Sig.
Type of ascites Degree of ascites distribution Total
Mild Moderate Severe
Symptomatic
15
13
34 62
Asymptomatic
1
2 5 8
Total 16 15 39 70
33
Fig (4.6): Shows the correlation between asymptomatic ascites and
theirdegrees.
Fig (4.7): Shows the correlation between symptomatic ascites and
theirdegrees
0.00%
2.00%
4.00%
6.00%
8.00%
Mild Moderate Severe
1 2
5
0%
10%
20%
30%
40%
50%
Mild Moderate Severe
1513
34
Asymptomatic Ascites
Per
cen
t %
Symptomatic Ascites
Per
cen
t %
34
Chapter Five
Discussion, Conclusion &Recommendations
34
5.1. Discussion
This study was done for seventy patients in Khartoum state to assessment
the role of ultrasound in diagnosing of pathologies associated with ascites.
According to the frequency distributions of the age,the most affected age
group ranging between (50-60) years, depends on the cause of ascites which was
comparatively more in age group above 50 years, like malignancy andorgan
failure which is acceptable when comparing that with what mentioned in the
previous studies.
Also the study showed that most patients with ascites were male with
percentage 72 % , and this agrees with the study done by (Esra Salah study
2010)(9), who found that the males were three times affected than females, because
male are more affected with liver pathologies which have linked with alcohol
abuse and shistosomiasis.
According to the frequency distribution of the degrees of ascites, the severe
ascites was most common.
Concerning the correlation between the symptoms and signs of the
pathologies associated with the ascites and their degree were depended on
progression ofthe causes of diseases, which also agree with what mentioned in
the previous study.
Regarding the frequency distributions of the causes of ascites , the portal
hypertension and liver diseases generally had high percent of all causes and this
also is acceptable when comparing with the study done by (Najla Hussein
2006)(8), who found that the common cause of ascites is the portal hypertension
and liver cirrhosis (83%).
The limit of ultrasound in present study was the deficiency of ultrasound
in differentiating betweenthetypes and nature of the cells in ascitic fluid (blood,
35
pus, cancer's cells or others); therefore fine needle biopsy under ultrasound
guidance and laboratory are needed.
36
5.2. Conclusion
The study conducted that ultrasound has been widely accepted as initial
screening procedure in patient with ascites and it is important and very sensitive
imaging technology which can differentiate between the two types of ascites, also
demonstrating the main cause of ascites, site and degree of it.
Thestudy showed that the most affected age was (50-60) years, male more
affected than females, the most degree was severe, symptoms ascites was more
common than asymptomatic and the most common causes was portal
hypertension and liver cirrhosis.
The study foundsignificant correlation betweensymptomatic ascites and their
degrees.
37
5.3 Recommendation
1- All primary health centers should be equipped well by high quality ultrasound
machines and good qualified sonographers.
2- Hepatitis B and schistosomiasis are very serious diseases, leading to liver
cirrhosis and threaten life.
3- Further studies must be done with large sample size to obtain accurate results.
References
38
1.Jane Bates. Abdomen. In: Dinah Thom (editor). Abdominal ultrasound How,
Why and When (2nd Ed), China, Elevier 2004; P: 6-8.
2.Richard L Drake. Abdomen. In: PatricaTannian (editor). Grays Anatomy for
Students (3rd Ed), Canada, Elsevier. 2014; P: 303-308.
3.Paul Butler, Adam W, M, Mitchell, Harold Ellis et al. Abdomen and pelvis. In:
Paul Butler, Adam W, M, Mitchell (editors). Applied radiological anatomy
(1stEd), Cambridge New York 2007; P: 45.
4. Alnumeiri MS, Ayad CE, Ahmed BH et al. Evaluation of Ascites and its
Etiology using Ultrasonography. J Res Development. 2015; 3:1.
5.Guenter Schmidt, Lucas Greiner, Dieter Nuernberg. Gastrointestinal tract. In:
Guenter Schmidt, Lucas Greiner, Dieter Nuernberg (editors), Differential
Diagnosis in ultrasound imaging, (2ndEd). Germany, Georg, 2013; P: 276.
6.Vinay Kumar, Abul K. Abbas, Jon C, Aster. Ascites. In: Robbins and Cotran
(editors). Pathologic Basis of Disease (9th Ed), Canada, Elsevier 2015; P: 884
7.Joanne C Rosenberg, Arnold, Laura J Zuidema, et al. Abdomen. In: Sandra L.
Hagen-Ansert (editors). Diagnostic ultrasonography (4thEd) Germany, Georg,
2015; vol (1): P 56.
8. Guenter Schmidt, Lucas Greiner, Dieter Nuernberg. Abdomen. In: Guenter
Schmidt, Lucas Greiner, Dieter Nuernberg (editors). Differential Diagnosis in
Ultrasound Imaging (2ndEd), Robert Hurler, Germany, 2013; P 76-352.
39
9. Carol M Rumack, Tephanie R Wilson, William Charboneau, et al. Liver. In:
Carol M Rumack, Tephanie R Wilson, William Charboneau (editors). Diagnostic
Ultrasound(4th Ed) USA, Elsevier, 2011; Vol 2 P 94-333.
10.http://search.handycafe.com/results?q=severe+case+of+ascites&l=sd&s=log
o&hl=sd. Sunday, April 28, 2017 11:14:05AM
11.http://search.handycafe.com/results?q=severe+case+of+ascites&l=sd&s=log
o&hl=sd&c=images. Sunday, April 28, 2017 12:24:12 PM
12.https://radiopaedia.org/assets/ gif. Sunday, April 28, 2017 12:24:12 PM
13."http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd".Sunday, April
28, 2017 12:50:57 AM
14. http://www.ultrasoundcases.info/files/Jpg/lbox_14892.jpg.Monday, April
28, 2017 02:24:12 PM
40
Appendices
41
Appendix1
US image (1) shows liver cirrhosis and portal hypertension with severe
ascites
US image (2) shows severe ascites in a patient with liver cirrhosis.
42
US image (3) shows shrunken liver, portal hypertension and chronic
cholecystitis with severe ascites.
US images (4) show moderate ascites in a female patient.
43
US images (5) show moderate ascites in a female patient.
US image (6) shows liver cirrhosis with severe ascites and chronic
cholecystitis.
44
US images (7) show moderate ascites due to liver cirrhosis.
US image (8)shows moderate ascites in a female patient due toliver
cirrhosis.
45
US images (9) show dilated hepatic veins and increased liver size with
moderate ascites in a patient with CHF.
US image (10) in a patient with Congestive heart failure shows dilated
hepatic vein and increased liver size.
46
US images (11) show dilated hepatic vein, liver increased in size and
pleural effusion in a patient with CHF.
US images (12) show decrease renal echogenicity and increased size of
kidneys in a patient with ARF.
47
US images (13) shows increased renal echogenicity and decrease in size
in a patient with CRF.
US images (14) show increased renal echogenicity and decreased in size
in a patient with CRF.
48
US images (15) in a patient with chronic renal failure show increased
renal echogenicity and decreased in size.
US image (16) shows large mass in the Rt liver lobe with mild ascites.
49
US image (17) shows irregular mass with mixed echogenicity and mild
ascites (CA).
US images (18) show UB mass in a male patient with (TCC).
50
US images (19) show moderate ascites in a female patient with huge
pelvic mass.
51
Appendix 2
The National Ribat University
Faculty of Graduate Studies and Scientific Research
Data collection sheet:
Assessment of Abdominal Ultrasound Findings in Patients with
Pathologies Associated Ascites
Date:…………… ………….. Index
Age: (18_29) (30_39) (40_49) (50_59) (60_69) > 70
Gender: M F
Clinical feature:
Symptomatic Asymptomatic
Site of the causativedisease: Liver affect:
Portal hypertention Budd-Chirai Syndrome Cirrhosis
Viral Hepatitis Hematoma Schistosomiasis Ca
Renal affect: Tumour Rena mets Renal failure
Nephrotic syndrome Renal dialysis Renal transplant
Heart affect:
CHF. Others.
Inflectious cause:
T B Peritonitis Serositis PID
Malignancy:
Primary peritoneal carcinomatosis
Rare:
Angioedema Malnutrition Meig's syndrome Vasculitis Hypothyroidism
Degree of ascitis: Mild ascites
Moderate ascites Severe ascites
Notes:……………………………………………………………………………………………………………………
…………………………………………………………….