The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Ascites & Venous Patterns


  • To demonstrate SHIFTING DULLNESS.
  • To demonstrate FLUID THRILL OR WAVE.

[Stanford 25 video forthcoming]


  • Fluid Thrill or Wave: (generally only works for tense ascites)
    • Ask pt or assistant to press the edge of one hand vertically down the midline of the abdomen.
    • Tap or flick one flank sharply with fingertips while palm of the other hand is resting on the other flank.
    • The positive finding is a “thril” which is a better descriptor than wave.
  • Shifting Dullness:
    • Begin percussing in the center or most protuberant part of the abdomen–you should hear tympany from air in the loops of bowel that have floated up.
    • Percuss laterally towards you from that point till you encounter dullness. KEEP YOUR FINGERS THERE.
    • Ask pt to turn to the side away from you.  Wait a few seconds (for fluid to move to the new dependent area and for bowel to float up).
    • Now when you percuss it should be tympanitic.
  • Because cirrhosis is the most common cause of ascites, many patients with ascites demonstrate the stigmata of liver disease.
  • An elevated JVP suggests a cardiac cause (e.g. heart failure, constrictive pericarditis) of ascites.

Prominent Venous Patterns on Abdominal Wall:

  • Need to distinguish three kinds of flow in visible veins.
    • Flow away from the umbilicus (portal hypertension).
    • Flow to the umbilicus (rare, in portal vein thrombosis).
    • Flow from down to up (IVC obstruction).

Written by stanford25admin

June 7, 2010 at 4:01 pm

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