0

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

11

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:……………………………………………………………………………………………………………………

…………………………………………………………….