Ascites Examination - Point of Care Ultrasound - Dr Gill

Hello and welcome back to the channel. Here's John, myself and Dr James Gill for another clinical skills video. Today we're going to be doing point of care ultrasound whereby we're looking at a patient with ascites. So ascites is one of these very important signs that we need to be able to identify rapidly. Bearing in mind if we're dealing with a patient who's coming in with acute abdominal swelling, they're perhaps having issues with nausea, vomiting, or pain, and we're considering there might be reasons to believe this is ascites, it is going to take some time for a liver function test to come back. Conversely, the ability to do a point-of-care ultrasound and identify that free fluid in the abdomen is going to be very useful in terms of planning out what is likely going to be the management plan for that patient. So with regard to that, obviously Do we want to introduce ourselves to the patient? Hello, my name's Dr Gill. I've been asked to do an ultrasound of your abdomen, your stomach area today. Before we go further, can I please confirm your name and date of birth? Yes, Dr Bethany Gill, and my date of birth is 10th August 1995. Fantastic, thank you. So, I'm aware that there's some concern about fluid in your abdomen. Have you had an ultrasound before? Not recently. Okay, so you're familiar with the nature of going to be putting some jelly on your stomach. Can I clarify it? It's very unlikely, but we always want to make sure with regard to the jelly. Do you have any allergies at all? No. Fantastic, thank you. So if I can get you to start, please, by lifting up your shirt. I'm going to need to get to this area of the skin just at the top of your ribs, thank you. So in terms of starting off with the ultrasound, obviously I've gel cleaned my hands beforehand. We're going to get the ultrasonic jelly, which will allow us to send the sound into and also receive the sound of the probe. So here we're going to be using the curvilinear transducer probe, and crucially I'm going to actually be turning the unit around so that I've got the nub faced toward the patient's head, and that way I will be able to correlate that with the left side of the screen pointed towards the patient's head and that'll help me orientate myself which is unfortunately not warmed in this case the screen is set to record and is using the abdominal setting i'm looking at the nub on the ultrasound probe and that is corresponding to the left side of the screen so in this case i'm going to turn the probe around so the probe is headed towards the patient's head and I know that the left side of the screen will therefore correspond with the patient's head. I'm just going to make a small touch on that to confirm exactly where we are. Now in terms of the first part of the examination we're going to be looking between the seventh and the tenth intercostal spaces and we're going to be looking through the ribcage at the liver so with ascites we are dealing with a free fluid within the abdomen as such we're looking for sharp clearly demarcated blackness because the fluid is anechoic by comparison if we're looking at fluid and things within the bowel then that's going to be um bordered and will likely be much blunter by comparison similarly because we're looking at fluid it's going to move within the abdominal cavity and will move downwards as the patient is lying we're going to expect it to collect in certain areas so for example we're looking to see if there is fluid in the potential space within the liver called Morrison's pouch if we can see evidence of fluid around the kidneys and if we can see anything in the paracolic gutters on the left and right side of the abdomen so it's starting off the patient is positioned in a position that lying flat and we've got their right arm up behind the head so i can get to this side so i'm just going to apply the probe now if that's okay so coming in to the side and straight away on the screen we've come in and we can see the echo texture and the vein the vessels and ducts of the liver there we go so we can see that what should normally be a flat line has been filled with black fluid but that's different from the spaces that I can trace up and down we're looking at the bile ducts I'm going to move a little bit lower and I'm going to try and find the the kidney instead of getting a little bit more ultrasound jelly I wasn't quite generous enough to start off with and we're looking down at the side and I'm trying to find the kidney again so we can see the kidney on the screen we can see that there is a darkness around it which is not unusual so we know that there is the ascetic fluid within the abdomen here and then I'm going to come down I'm just going to move your trousers ever so slightly and just changing the direction of the probe here So I've rotated around, and now the probe is facing towards me, so the dot on the screen is with the right side of the patient. I'm looking around, I'm checking in the paracolic gutters, can I see any loops of bowel, and crucially, can I see that free fluid within the abdomen? We can also move over and check the same side. Again, can I see this very clearly demarcated darkness in keeping with the free fluid? If we wish to, we can actually come across suprapubically to view the bladder, which we can see there as a dark horizontal shape. So we can see there how that is demarcated. This dark horizontal shape is boundaried, as we're expecting with the bladder, which is not the case when we've seen that free fluid within the abdomen. We can also, if needed, have a look around the liver. Now, throughout this, we're looking for darkness which is not there. So keeping in mind that the intestines and things are sat within the abdominal cavity and we've not got any extra space particularly around them. So ascites shows up very clearly on the ultrasound. In this case, we could see a small amount of fluid. And then when we've identified ascites, we need to ask the question, why? So is it an exudate, indicating that there's protein within the abdominal cavity? Or are we dealing with a transudate, where actually there's less protein in the abdomen in terms of it being pushed through? That will tell us an awful lot about the pathological processes. Now, in this particular case, I have got consent to film, I've confirmed this, the ascites that we're dealing with here today is by definition transudative because it's actually a consequence of a surgical procedure where free fluid has been left in the abdomen which is entirely safe and this will resolve without complication and that's one of the reasons we've been able to film this today so hopefully this has been a useful video for yourselves looking at point of care ultrasound with regard to ascites if you've got any questions please put them in the comments and see what we can do to help. Take care and we'll see you in the next one, cheerio