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111
Ultrasonic Differentiation Types of Ascitic Fluid
of
,
Steven and
Warren
L. EdeIl1 B. Gefter2
A review of 65 cases of proven ascites was done to assess the accuracy of ultrasound in distinguishing transudates from exudates. In 10 patients with malignant ascites, ultrasound suggested this in six by showing mailed bowel loops, loculation, or hepatic metastasis. In each of the five patients with peritonitis, infected ascites was suggested by observing septations or debris within the fluid. A sonographic diagnosis of exudate
was not made in any of the 50 confirmed which
may suggest
In recent
infected
years
ultrasound
has been
proven
determining therapy [1
1. However,
assess sition,
has
an accurate
its distribution, there
to distinguish
simple
how accurately we correlated
transudates.
or malignant
ascites
found
The echographic
increasing
and reliable
characteristics
are discussed.
use
method
in evaluating
of detecting
guiding paracentesis, and monitoring has been little emphasis on the ability
transudates
from
inflammatory
It
fluid,
the effects of ultrasound
or malignant
the sonographic characteristics the sonograms and clinical records
ascites.
abdominal
exudates.
of
To
reflect the fluid compoof 65 cases of proven
ascites.
Materials
and Methods
Gray scale B-mode ultrasound was performed on 1 47 patients with clinically suspected ascites at the Philadelphia Veterans Administration Hospital from September 1 978 to August 1 978. A commercially available Picker 80-L scanner using a 2.25 MHz internally focused transducer was used. Of these 1 47 patients, 89 were thought to have detectable abdominal
Received September revision March 5, 1979 1
Department
14,
1978;
of Radiology,
University
sylvania istration
School of Medicine, and Hospital, Philadelphia,
19104.
Present
address:
Department
of Radiology,
print
requests
AJR
133:111-114,
1 979
American
of Penn-
of Radiol-
Boulevard,
University
sylvania School of Medicine, Philadelphia, Pennsylvania
©
Lea
after
Veterans AdminPennsylvania
Department
ogy, Riverside Hospital, 700 mington, Delaware 19899. 2
accepted
Wil-
of Penn-
3400 Spruce Street, 1 91 04. Address re-
fluid
by ultrasound
examination.
The
clinical
charts
of these
89
patients
were
then reviewed. The nature of the ascitic fluid was confirmed in 65 patients by paracentesis or laparotomy. The sonograms in these 65 cases were then reviewed retrospectively and without knowledge oftheir clinical diagnosis. Distribution of fluid, matting together of bowel loops, echoes within the fluid spaces, associated masses, lymphadenopathy, and hepatic metastases were evaluated in each case. These findings were then correlated with the fluid type. The fluid defined as transudative ascites was low in protein (less than 3 mg/i 00 ml) and other
colloids
and
of low
specific
gravity,
usually
below
1 .01 2. The
exudative
fluid,
other hand, had a higher content of plasma proteins and cells with a specific gravity above 1 .020. All opinions were the consensus of a single multiobserver review.
on the
usually
Results
to W. B. Gefter. July Roentgen
0361-803X/79/1331-01
1979 Ray
Society
1 1 $00.00
Etiologies of abdominal fluid in the 65 shown in table 1 . There were 50 transudates of the
ultrasonic
findings
in these
cases
patients and
is summarized
with confirmed 1 5 exudates. The in table
2.
ascites are distribution
112
EDELL
TABLE
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Etiologies
in Cases
AND
GEFTER
AJR:133,
July
1979
1
of Confirmed
Ascites
Etiology
No
Patients
Transudates: Cirrhosis
42
Congestive heart failure Chronic renal disease Miscellaneous
2 3 3
Subtotal
50
Exudates: Malignancy
10
Peritonitis:
Tuberculous
2
Pyogenic
3_
Subtotal
1
Total
65 Fig. rounding
TABLE Distribution
1 -Right bowel
longitudinal sonogram. loops (BL) and liver (L).
Transudative H
=
head,
ascitic
F
=
fluid
(A)
sur-
feet.
2
of Ultrasonic Findings Among Exudative Ascites
Transudative
and
Exudates
Ascites
Pattern infective
Atypical: Debris Septations
Matted
bowel
Loculated
loops
fluid
Hepatic
metastasis
Typical
In the findings
50
0
3
0
0
1
0
0
2
of transudative
typical
50
10
50
of simple
ascites, fluid.
the abdomen within the ascitic
the
The and fluid
ultrasonic
fluid
was
evenly
bowel loops (fig. 1).
were
Ascites
Two echoes
cases within
culous
peritonitis
grossly
turbid
normal
of exudative the fluid (fig. Three
bands
peritonitis numerous correlating
well several
cases
persistently
patients
possibly
accounting
showing
were
the
loops
also
cases,
hepatic
Four
patients
with
(fig.
malignant.
proved
such the
picture.
of bowel 4 and
(interlacing case revealed purulent fluid, Three
within 5).
to be malignant
metastasis suggested ‘ ‘typical’ ‘ fluid patterns
was
to pyogenic Fig. 2.-Right longitudinal sonograms peritonitis. A. Ascitic fluid (A) with areas
patients
H
interposed
The
patient
of fluid
fluid
for the ab-
secondary
In one
collection
the
septations
each
ultrasonic
sonograms was
loculated
which
In these
cases
or matted
other
showing small amorphous were found to have tuber-
‘)
Laparotomy in one strands throughout
with
adherent
on
2).
of echoes) (fig. 3). fibrotic
showed
ascites
‘debris’
(‘
and cellular,
echoes.
linear
0
4
A
cases
were
Exudative
space,
0 0
Ascites
dispersed throughout seen to float freely
these
0 0
5
Transudative
Transudates
2 3
-_0
Total
fluid
Neopiastic
ascites
there
in the
(fig.
=
fluid.
head, F = feet. B, Ascitic H = head, F = feet.
in two of debris
fluid (A) with areas
patients (0)
with
tuberculous
in dependent
of debris
(D) floating
portion.
in the
in
was
a
retrovesical
6). In two
neoplastic fluid. proved to have
malignant malignancy fluid nitis.
ascites (table 2). Therefore, in six of the 1 0 patients
and infection in five Table 3 summarizes
sonograms
suggesting
ultrasound (60%) with
of five cases the diagnoses
exudative
ascites.
suggested neoplastic
(1 00%) with peritoin those cases with
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 04/14/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
AJR:133,
July
ULTRASOUND
1979
Fig. 3.-Right longitudinal sonogram Numerous septations (5) within ascitic feet.
in patient with pyogenic fluid (A). L = liver, H =
Fig. Matted
in patient (A), and liver
4.-Right longitudinal loops of bowel (MB),
structures.
H
=
head,
F
=
OF
peritonitis. head, F
ASCITIC
Fig. -
Matted
tion.
sonogram fluid
ascitic
5-Right loops
A
113
FLUID
=
longitudinal sonogram in patient with malignant (MB) containing fluid secondary to intestinal fluid, L = liver, H = head, F = feet.
of bowel
ascitic
with malignant ascites. (L) adherent to adjacent
feet.
TABLE 3
Discussion Echographic The
evaluation
abdominal
[2-4].
neous, tween manner
of ascites
ultrasound,
distinguishing
described
fluid
the
typical
Intraperitoneal
echo-free
since from
solid
was
one
this
method
tissue
sonographic fluid
areas
the loops of bowel (fig. 1 ). The bowel
of the
generally
loops
viscera
the
various
intraperitoneal
uses
series
for have
of ascites
appears
as
and
interposed
in a relatively
homoge-
be-
in Exudative
Echographic
findings
Debris within Septations
fluid
2 3
Tuberculous peritonitis Pyogenic peritonitis
Matted
loops
3
Hepatoma
fluid
1
metastasis
2
Bronchogenic carcinoma, with rectal metastasis Pancreatic carcinoma, colon carcinoma
bowel
Loculated Hepatic
gas and fluid and the of ascites is thought as capillary attraction [3].
amounts of fluid tend to collect in the flanks right paracolic gutter, around the liver, and peritoneal reflection in the pelvis [3, 4].
The
Ascites
smallest
and superior in the lowest
Diagnosis
Paii:nts
uniform
may float or sink depending
spaces
Findings
of
suited
Several
appearance
surrounding and
earliest
is ideally
[2].
on the relative amount of intraluminal density of ascitic fluid. The distribution to reflect the effects of gravity as well in
ascites. obstruc-
(2),
metastasis
(1)
In reviewing the 65 cases of ascites, we found the above features to apply in most cases. However, 1 1 cases (about 1 8%) each
showed case
the
atypical fluid
was
sonographic an exudate,
characteristics either
inflammatory
and
in or
114
EDELL
malignant.
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 04/14/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
the
Therefore
usual
fluid
we believe
pattern
should
ascites, to be distinguished transudates. In each
case
fluid
collections,
the
sonograms
that
from
in which
echoes
ascites
deviations
an exudative
the more
abnormal
the
certain
suggest
proved
typical were
AND
from form
of
finding
in
seen
to be infected.
within
patients had the form of either groups (‘ debris’ ‘) in the cases of tubercuor the course network of echoes generated
fine
bus
peritonitis,
from
the
strands
in purulent
collections.
Such
inho-
mogeneous fluid patterns, then, in the appropriate clinical setting should raise the possibility of infected ascites. These echoes, of course, must be differentiated from the bowel or mesentery.
Goldberg fluid
[1
or infiltration
]
suggested
that
of bowel
loops
irregular
accumulations
are suggestive
of
of malignant
ascites. These findings are supported in our series. Matting of bowel loops was seen in only three cases, each having neoplasm, two with hepatoma and one with metastatic carcinoma.
Bowel
should
be considered
matted
or
infiltrated
only if loops fail to be separated by fluid consistently on several scans, despite changes in position. Adherence of liver to adjacent structures was also noted in a case of hepatoma. A loculated pocket of fluid was seen in one patient who proved to have malignant ascites from metastatic bronchogenic carcinoma. While the differentiation between benign and malignant
ascites
by
difficult
or impossible
ultrasound
has [3],
been
it can
regarded be seen
as frequently that
certain
fluid. This of fluid were transudative
bowel
adhesions,
it is possible
that
1979
a pattern
simulating malignant ascites might be created. However, we did not observe any such cases. As had been noted by others, additional sonographic findings including hepatic other
abdominal
indirect
ings
signs
was particularly true present. On the other ascites is associated
described
and the and one
masses,
and
lymphadenopathy
of malignant
fluid
[1
,
are
3].
above.
liver case
In all of these
were surrounded of chylous ascites
cases
by fluid.
the
One
bowel
case
loops
of bilious
were also studied and failed to demonstrate any distinctive features. Because the patient population in our study was almost exclusively
male,
we
cases of ovarian malignant ascites. altered
the
ated and
did
not
have
the
presented
that
workup of false
was done, negatives
the morbidity of paracentesis one-third of our suspected
to study
common cases may
cause of well have
here.
58 of the original
for ascites showed no ultrasonically more definitive studies were not
no further possibility
opportunity
carcinoma, a relatively The addition of such
statistics
It is of interest
1 47 patients
evalu-
demonstrable fluid, performed. Because
we cannot entirely exclude in these patients. Nevertheless, was thereby avoided cases of ascites.
the
in about
REFERENCES
ultra-
sonic patterns may aid in this distinction. Matted loops of bowel, plastering of the liver to surrounding structures, and loculation of fluid, when present, are very suggestive of malignant ascites. However, the absence of these findings did not exclude neoplastic when only small amounts hand, in situations where
preexisting
July
None of the cases of transudative ascites, namely those secondary to cirrhosis, congestive heart failure, or chronic renal disease, demonstrated the ‘ ‘atypical’ ‘ ultrasonic find-
echoes
fibrous
with
AJR:133,
metastasis,
The
in these
of multiple
GEFTER
1
.
Goldberg BB: Ultrasonic JAMA 235:2427-2430,
2. Goldberg
BB, Goodman
by ultrasound. 3, Yeh HC, Wolf 783-790,
evaluation 1976
GA, Clearfield
of
intraperitoneal
HR: Evaluation
Radiology 96 : 1 5-22, 1970 BS: Ultrasonography in ascites.
fluid.
of ascites
Radiology
124:
1977
4, Proto AV, Lane EJ, Marangola distribution. AJR 126:974-980,
JP: A new concept 1976
of ascitic
fluid
111
Ultrasonic Differentiation Types of Ascitic Fluid
of
,
Steven and
Warren
L. EdeIl1 B. Gefter2
A review of 65 cases of proven ascites was done to assess the accuracy of ultrasound in distinguishing transudates from exudates. In 10 patients with malignant ascites, ultrasound suggested this in six by showing mailed bowel loops, loculation, or hepatic metastasis. In each of the five patients with peritonitis, infected ascites was suggested by observing septations or debris within the fluid. A sonographic diagnosis of exudate
was not made in any of the 50 confirmed which
may suggest
In recent
infected
years
ultrasound
has been
proven
determining therapy [1
1. However,
assess sition,
has
an accurate
its distribution, there
to distinguish
simple
how accurately we correlated
transudates.
or malignant
ascites
found
The echographic
increasing
and reliable
characteristics
are discussed.
use
method
in evaluating
of detecting
guiding paracentesis, and monitoring has been little emphasis on the ability
transudates
from
inflammatory
It
fluid,
the effects of ultrasound
or malignant
the sonographic characteristics the sonograms and clinical records
ascites.
abdominal
exudates.
of
To
reflect the fluid compoof 65 cases of proven
ascites.
Materials
and Methods
Gray scale B-mode ultrasound was performed on 1 47 patients with clinically suspected ascites at the Philadelphia Veterans Administration Hospital from September 1 978 to August 1 978. A commercially available Picker 80-L scanner using a 2.25 MHz internally focused transducer was used. Of these 1 47 patients, 89 were thought to have detectable abdominal
Received September revision March 5, 1979 1
Department
14,
1978;
of Radiology,
University
sylvania istration
School of Medicine, and Hospital, Philadelphia,
19104.
Present
address:
Department
of Radiology,
requests
AJR
133:111-114,
1 979
American
of Penn-
of Radiol-
Boulevard,
University
sylvania School of Medicine, Philadelphia, Pennsylvania
©
Lea
after
Veterans AdminPennsylvania
Department
ogy, Riverside Hospital, 700 mington, Delaware 19899. 2
accepted
Wil-
of Penn-
3400 Spruce Street, 1 91 04. Address re-
fluid
by ultrasound
examination.
The
clinical
charts
of these
89
patients
were
then reviewed. The nature of the ascitic fluid was confirmed in 65 patients by paracentesis or laparotomy. The sonograms in these 65 cases were then reviewed retrospectively and without knowledge oftheir clinical diagnosis. Distribution of fluid, matting together of bowel loops, echoes within the fluid spaces, associated masses, lymphadenopathy, and hepatic metastases were evaluated in each case. These findings were then correlated with the fluid type. The fluid defined as transudative ascites was low in protein (less than 3 mg/i 00 ml) and other
colloids
and
of low
specific
gravity,
usually
below
1 .01 2. The
exudative
fluid,
other hand, had a higher content of plasma proteins and cells with a specific gravity above 1 .020. All opinions were the consensus of a single multiobserver review.
on the
usually
Results
to W. B. Gefter. July Roentgen
0361-803X/79/1331-01
1979 Ray
Society
1 1 $00.00
Etiologies of abdominal fluid in the 65 shown in table 1 . There were 50 transudates of the
ultrasonic
findings
in these
cases
patients and
is summarized
with confirmed 1 5 exudates. The in table
2.
ascites are distribution
112
EDELL
TABLE
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 04/14/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
Etiologies
in Cases
AND
GEFTER
AJR:133,
July
1979
1
of Confirmed
Ascites
Etiology
No
Patients
Transudates: Cirrhosis
42
Congestive heart failure Chronic renal disease Miscellaneous
2 3 3
Subtotal
50
Exudates: Malignancy
10
Peritonitis:
Tuberculous
2
Pyogenic
3_
Subtotal
1
Total
65 Fig. rounding
TABLE Distribution
1 -Right bowel
longitudinal sonogram. loops (BL) and liver (L).
Transudative H
=
head,
ascitic
F
=
fluid
(A)
sur-
feet.
2
of Ultrasonic Findings Among Exudative Ascites
Transudative
and
Exudates
Ascites
Pattern infective
Atypical: Debris Septations
Matted
bowel
Loculated
loops
fluid
Hepatic
metastasis
Typical
In the findings
50
0
3
0
0
1
0
0
2
of transudative
typical
50
10
50
of simple
ascites, fluid.
the abdomen within the ascitic
the
The and fluid
ultrasonic
fluid
was
evenly
bowel loops (fig. 1).
were
Ascites
Two echoes
cases within
culous
peritonitis
grossly
turbid
normal
of exudative the fluid (fig. Three
bands
peritonitis numerous correlating
well several
cases
persistently
patients
possibly
accounting
showing
were
the
loops
also
cases,
hepatic
Four
patients
with
(fig.
malignant.
proved
such the
picture.
of bowel 4 and
(interlacing case revealed purulent fluid, Three
within 5).
to be malignant
metastasis suggested ‘ ‘typical’ ‘ fluid patterns
was
to pyogenic Fig. 2.-Right longitudinal sonograms peritonitis. A. Ascitic fluid (A) with areas
patients
H
interposed
The
patient
of fluid
fluid
for the ab-
secondary
In one
collection
the
septations
each
ultrasonic
sonograms was
loculated
which
In these
cases
or matted
other
showing small amorphous were found to have tuber-
‘)
Laparotomy in one strands throughout
with
adherent
on
2).
of echoes) (fig. 3). fibrotic
showed
ascites
‘debris’
(‘
and cellular,
echoes.
linear
0
4
A
cases
were
Exudative
space,
0 0
Ascites
dispersed throughout seen to float freely
these
0 0
5
Transudative
Transudates
2 3
-_0
Total
fluid
Neopiastic
ascites
there
in the
(fig.
=
fluid.
head, F = feet. B, Ascitic H = head, F = feet.
in two of debris
fluid (A) with areas
patients (0)
with
tuberculous
in dependent
of debris
(D) floating
portion.
in the
in
was
a
retrovesical
6). In two
neoplastic fluid. proved to have
malignant malignancy fluid nitis.
ascites (table 2). Therefore, in six of the 1 0 patients
and infection in five Table 3 summarizes
sonograms
suggesting
ultrasound (60%) with
of five cases the diagnoses
exudative
ascites.
suggested neoplastic
(1 00%) with peritoin those cases with
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 04/14/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
AJR:133,
July
ULTRASOUND
1979
Fig. 3.-Right longitudinal sonogram Numerous septations (5) within ascitic feet.
in patient with pyogenic fluid (A). L = liver, H =
Fig. Matted
in patient (A), and liver
4.-Right longitudinal loops of bowel (MB),
structures.
H
=
head,
F
=
OF
peritonitis. head, F
ASCITIC
Fig. -
Matted
tion.
sonogram fluid
ascitic
5-Right loops
A
113
FLUID
=
longitudinal sonogram in patient with malignant (MB) containing fluid secondary to intestinal fluid, L = liver, H = head, F = feet.
of bowel
ascitic
with malignant ascites. (L) adherent to adjacent
feet.
TABLE 3
Discussion Echographic The
evaluation
abdominal
[2-4].
neous, tween manner
of ascites
ultrasound,
distinguishing
described
fluid
the
typical
Intraperitoneal
echo-free
since from
solid
was
one
this
method
tissue
sonographic fluid
areas
the loops of bowel (fig. 1 ). The bowel
of the
generally
loops
viscera
the
various
intraperitoneal
uses
series
for have
of ascites
appears
as
and
interposed
in a relatively
homoge-
be-
in Exudative
Echographic
findings
Debris within Septations
fluid
2 3
Tuberculous peritonitis Pyogenic peritonitis
Matted
loops
3
Hepatoma
fluid
1
metastasis
2
Bronchogenic carcinoma, with rectal metastasis Pancreatic carcinoma, colon carcinoma
bowel
Loculated Hepatic
gas and fluid and the of ascites is thought as capillary attraction [3].
amounts of fluid tend to collect in the flanks right paracolic gutter, around the liver, and peritoneal reflection in the pelvis [3, 4].
The
Ascites
smallest
and superior in the lowest
Diagnosis
Paii:nts
uniform
may float or sink depending
spaces
Findings
of
suited
Several
appearance
surrounding and
earliest
is ideally
[2].
on the relative amount of intraluminal density of ascitic fluid. The distribution to reflect the effects of gravity as well in
ascites. obstruc-
(2),
metastasis
(1)
In reviewing the 65 cases of ascites, we found the above features to apply in most cases. However, 1 1 cases (about 1 8%) each
showed case
the
atypical fluid
was
sonographic an exudate,
characteristics either
inflammatory
and
in or
114
EDELL
malignant.
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 04/14/15 from IP address 128.122.253.228. Copyright ARRS. For personal use only; all rights reserved
the
Therefore
usual
fluid
we believe
pattern
should
ascites, to be distinguished transudates. In each
case
fluid
collections,
the
sonograms
that
from
in which
echoes
ascites
deviations
an exudative
the more
abnormal
the
certain
suggest
proved
typical were
AND
from form
of
finding
in
seen
to be infected.
within
patients had the form of either groups (‘ debris’ ‘) in the cases of tubercuor the course network of echoes generated
fine
bus
peritonitis,
from
the
strands
in purulent
collections.
Such
inho-
mogeneous fluid patterns, then, in the appropriate clinical setting should raise the possibility of infected ascites. These echoes, of course, must be differentiated from the bowel or mesentery.
Goldberg fluid
[1
or infiltration
]
suggested
that
of bowel
loops
irregular
accumulations
are suggestive
of
of malignant
ascites. These findings are supported in our series. Matting of bowel loops was seen in only three cases, each having neoplasm, two with hepatoma and one with metastatic carcinoma.
Bowel
should
be considered
matted
or
infiltrated
only if loops fail to be separated by fluid consistently on several scans, despite changes in position. Adherence of liver to adjacent structures was also noted in a case of hepatoma. A loculated pocket of fluid was seen in one patient who proved to have malignant ascites from metastatic bronchogenic carcinoma. While the differentiation between benign and malignant
ascites
by
difficult
or impossible
ultrasound
has [3],
been
it can
regarded be seen
as frequently that
certain
fluid. This of fluid were transudative
bowel
adhesions,
it is possible
that
1979
a pattern
simulating malignant ascites might be created. However, we did not observe any such cases. As had been noted by others, additional sonographic findings including hepatic other
abdominal
indirect
ings
signs
was particularly true present. On the other ascites is associated
described
and the and one
masses,
and
lymphadenopathy
of malignant
fluid
[1
,
are
3].
above.
liver case
In all of these
were surrounded of chylous ascites
cases
by fluid.
the
One
bowel
case
loops
of bilious
were also studied and failed to demonstrate any distinctive features. Because the patient population in our study was almost exclusively
male,
we
cases of ovarian malignant ascites. altered
the
ated and
did
not
have
the
presented
that
workup of false
was done, negatives
the morbidity of paracentesis one-third of our suspected
to study
common cases may
cause of well have
here.
58 of the original
for ascites showed no ultrasonically more definitive studies were not
no further possibility
opportunity
carcinoma, a relatively The addition of such
statistics
It is of interest
1 47 patients
evalu-
demonstrable fluid, performed. Because
we cannot entirely exclude in these patients. Nevertheless, was thereby avoided cases of ascites.
the
in about
REFERENCES
ultra-
sonic patterns may aid in this distinction. Matted loops of bowel, plastering of the liver to surrounding structures, and loculation of fluid, when present, are very suggestive of malignant ascites. However, the absence of these findings did not exclude neoplastic when only small amounts hand, in situations where
preexisting
July
None of the cases of transudative ascites, namely those secondary to cirrhosis, congestive heart failure, or chronic renal disease, demonstrated the ‘ ‘atypical’ ‘ ultrasonic find-
echoes
fibrous
with
AJR:133,
metastasis,
The
in these
of multiple
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.
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fluid.
of ascites
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4, Proto AV, Lane EJ, Marangola distribution. AJR 126:974-980,
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of ascitic
fluid
