Evaluation of Ascites by Ultrasound'

BARRY B. GOLDBERG, M.D., GERALD A. GOODMAN, M.D.,2 and

HARRIS R. CLEARFIELD, M.D.

Ans'rzacr-e-Ultrasound was used to determine the presence of free intraperi-

toneal fluid. Base-line values were obtained by introducing known amounts
of fluid into the peritoneal cavities of cadavers and obtaining readings in mul-
tiple positions, the right lateral decubitus and hand-knee positions being the
most sensitive. As little as 100 ml of fluid could be detected. Ultrasonic pat-
terns changed with repositioning of the patient, confirming the presence of free
intraperitoneal fluid rather than loculated collections.
INDEX TERMS: Ascites. Peritoneum. Ultrasounds
Radiology 96: 15-22, July 1970

evaluation of ascites that ultrasonography can be used to de-

T HE CLINICAL
suffers from known limitations, par-
ticularly in instances of minimal free intra-
tect minimal amounts of free intraperi-
toneal fluid, since this technique has al-
peritoneal fluid; and numerous radio- ready proved capable of distinguishing
graphic signs have been proposed to im- cystic and solid masses as small as a few
prove diagnostic accuracy (1-3). Al- centimeters (11, 12). Experiments with
though several of these have proved help- cadavers and patients were carried out
ful-the hepatic angle and the flank stripe, to detect and quantitate free intraperi-
for example-many others have been dis- toneal fluid, and ultrasonic readings were
carded because of the high frequency of obtained in multiple positions to find the
false-positive results (4, 5). Even the arrangement most sensitive to small
flank stripe, one of the most sensitive of amounts of ascites. The multiple position
radiographic signs, has been shown experi- approach was also used to demonstrate a
mentally to require at least 800-1,000 ml change in the fluid pattern, thus differ-
of free fluid to become positive (4). Al- entiating between free and loculated fluid.
though Lawson and Weissbein (6) report
TECHNIQUE
that 120 ml of free intraperitoneal fluid
can be detected by physical diagnosis, us- A commercially available ultrasonic
ing percussion, most authors feel that instrument equipped with a standard 2.25
significantly greater amounts must be pres- megacycle transducer was used. The ul-
ent before clinical detection is possible (4). trasonic echo patterns obtained were dis-
The ability of ultrasound to detect as- played on an oscilloscope and recorded
cites has been mentioned only incidentally using Polaroid film. We employed A-
(7-10), with no attempt to quantitate the mode ultrasonographic technique and dis-
amount of fluid; indeed, all of the reported play, in which the height of the vertical
cases concerned massive ascites. We feel deflection of the trace represents the
1 From Episcopal Hospital (B. B. G. and G. A. G., Associate Radiologists; H. R. c., Head, Section of Gastro-
enterology) and Temple University (B. B. G., Assistant Professor of Radiology; G. A. G., Assistant Professor of
Radiology; H. R. C., Clinical Assistant Professor of Medicine), Philadelphia, Penna. Presented at the Fifty-
fifth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, Ill., Nov. 30-
Dec. 5, 1969.
2 Currently Associate Radiologist, Reading Hospital, West Reading, Penna. sjh
15
16 B. B. GOLDBERG, G. A. GOODMAN, AND H. R. CLEARFIELD July 1970

SUPINE FLANK AND LATERAL DECUBITUS POSITIONS HAND - KNEE POSITION (PRONE)

A
LATERAL DECUBITUS AND SUPINE --
pas IT, ONS

SUPINE POSITION

JLJl B
Fig. 1. Patient and transducer positi~nsJ with the
corresponding ultrasonic patterns. !he mtra-abdo.m-
inal blackened area represents ascites. A. Supine
right or left flank and lateral dec~bitus positio.ns.
B. Right or left lateral decubitus and supme pOS1-
.
c
tions.
C. Hand-knee and supine positions. the gain settings are too high. The strong
back wall echoes are the result of the
strength of an echo while the distance along
high specific acoustic impedance at the
the trace represents the tissue depth from
fluid-solid interface; the fluid itself is
which the echo arises. The machine was
transonic and echo-free. Such a pattern
set to provide uniformly increasing ampli-
is seen in ascites. When no fluid is
fication of the echo signals from the trans-
present, multiple echoes arising from inter-
ducer artifact to a tissue depth of 15 em.
faces between various abdominal organs
The gain controls were positioned midway
will be recorded. A commercially avail-
between the high and low settings used to
able water-soluble gel was applied between
distinguish cystic and solid masses (11,
the transducer and abdomen to secure good
12). Empirically, the transducer can be
acoustic coupling.
placed over a full urinary bladder and the
In our standard examination, five pairs
controls adjusted until an echo-free zone
of readings were obtained; in each, the
followed by multiple strong echoes is
patient's position was changed but the
obtained; these represent the urine and the
transducer remained fixed (Fig. 1). The
back wall of the bladder, respectively.
readings were as follows:
If multiple back wall echoes are not ob-
tained, the gain settings are too low; if the 1. Supine left flank and right lateral
clear zone representing the fluid begins to decubitus positions with the trans-
decrease significantly due to reverbera- ducer placed on the left flank
tions originating from the bladder walls, 2. Right lateral decubitus and supine
Vol. 96 EVALUATION OF ASCITES BY ULTRASOUND 17

positions with the transducer placed decreased significantly when the trans-
on the portion of the right side of ducer position was fixed and the patient's
the abdomen nearest the table dependent position changed. If the trans-
3. Supine right flank and left decubitus ducer was placed too high, confusing pat-
positions with the transducer placed terns from the gallbladder, liver, and spleen
on the right flank were sometimes encountered. The gall-
4. Left lateral decubitus and supine bladder was seen as a relatively fixed
positions with the transducer placed fluid pattern, whereas the liver and spleen
on the portion of the left side of the produced a solid rather than cystic echo
abdomen nearest the table complex. If the transducer was placed
5. Hand-knee and supine positions with too near the pubis in the hand-knee posi-
the transducer placed on the mid-ab- tion, the echoes from a full urinary bladder
domen. The patient assumes the could be recorded, and the fixed echo pat-
hand-knee position and bends his tern established the fluid as loculated
elbow slightly so that the anterior rather than free. A similar pattern was seen
abdominal wall is parallel to the in abscesses or cysts. Above the umbilicus,
table. confusing echoes from the aorta could be
differentiated from ascites by the demon-
In all readings, the transducer is moved stration of expansile motion of the aortic
until the maximum fluid pattern is ob- wall echoes (13).
tained. The first position was uniformly A few scattered echoes were sometimes
more sensitive than the second; the latter seen arising from within the echo-free
was used only to demonstrate a change in zone. These were most likely due to
the echo-clear space and thus establish abdominal organs, mainly the bowel. In
the presence of free fluid. For this reason, several cases, particularly in massive as-
when referring back to our standard tech- cites when the patient was repositioned
nique for the purpose of describing relative without moving the transducer, the ultra-
sensitivities, only the first position will be sonic fluid space did not disappear com-
used and will be designated as (a) supine- pletely. However, there was always a
left flank, (b) right lateral decubitus, (c) significant decrease in the echo-free zone,
supine-right flank, (d) left lateral de- indicating that the major portion of the
cubitus, or (e) hand-knee. fluid was basically free within the peri-
In all positions, about one minute should toneal cavity. The remaining echo-free
elapse before recording the echo pattern zone may represent fluid trapped within
in order to allow sufficient time for move- one of the spaces making up the peritoneal
ment of the ascites. Free fluid will settle cavity (14).
to the most dependent part of the abdo-
men. The examination was performed in RESULTS
the sequence given in order to minimize
patient movement. Some patients were A. Experimental: Ultrasonic studies
too sick to assume the hand-knee position, for possible ascites were made on 14 cadav-
and in such cases this position was e1im- ers, using the previously described posi-
inated; however, the remaining positions tions. Ten were found to have no ultra-
could be assumed easily by all patients. sonic evidence of free intraperitoneal fluid;
The measurements were obtained with of these, immediate autopsies confirmed
the patient in bed if necessary, although a the absence of ascites in 5. In 5 other
hard surface was preferred, particularly for cadavers, varying amounts of fluid were
the lateral decubitus positions. The best introduced into the peritoneal cavity and
ultrasonic readings were obtained around serial ultrasonic tracings were obtained.
the level of the umbilicus. The echo fluid In 3, a 14 gauge blunt needle was placed
pattern obtained in ascites disappeared or into the peritoneal cavity midway be-
18 B. B. GOLDBERG, G. A. GOODMAN, AND
Fig. 2. Roentgenograms demonstrate 500 ml of
contrast material in the peritoneal cavity, with the
corresponding ultrasonic tracings. The white arrows
represent transducer placement; black arrows define
the echo-free zone produced by the intraperitoneal
contrast material. A. Upright tracings obtained in
the supine flank positions, with inverted tracings ob-
tained in the corresponding lateral decubitus positions.
B. Upright tracing obtained in the right lateral
decubitus position, with an inverted tracing obtained
in the supine position.
C. Upright tracing obtained in the left lateral
decubitus position, with an inverted tracing obtained in
the supine position.
D. Upright tracing obtained in the hand-knee
position, with an inverted tracing obtained in the supine
position.
No Flui d
Introduced
100 ml
Introduced
150 ml Added
( t ot aI :: 250 mI )
250 ml Added
( t ota I = 500 mI )
Fig. 3. The echo-free zone increases with an in-
crease in the volume of intraperitoneal fluid.
H. R. CLEARFIELD July 1970
illl.11i111
--~
tween the umbilicus and the pubis. In
the remaining 2, a small incision was made
in the same area and a self -retaining bal-
loon-type catheter was positioned in the
peritoneal cavity. The balloon was in-
flated with water and the catheter sutured
tightly to the abdomen to prevent leakage
from about the site of the incision. In 2
cadavers, isotonic saline was introduced in
amounts ranging from 50 to 500 ml. In
the other 3, the saline was mixed with
water-soluble iodinated contrast material
in a ratio of 4: 1 and introduced in amounts
ranging from 100 to 500 m!. Serial ultra-
sonic recordings were made in all five
pairs of positions, and roentgenograms
confirming the ultrasonic findings were
obtained (Fig. 2).
No ultrasonic fluid pattern could be
found with 50 ml. With 100 ml, how-
ever, a fluid pattern was obtained in all 5
cadavers in the prone (hand-knee) and
right lateral decubitus positions. The
supine position with the transducer on the
right flank (supine right flank) was posi-
tive in 4 instances. The left lateral
Vol. 96 EVALUATION OF ASCITES BY ULTRASOUND 19

TABLE I: ECHO-FREE FLUID SPACE

Mean Mean
Width Width
of of
Echo- Range Echo- Range
Free (mm) Free (mm)
Space Space
(mm) (mm)
100 ml 500 ml
Right lateral decubi-
tus 13 4-30 45 22-52
Hand-knee 11 4-16 23 16-35
Supine right flank 9 0-16 37 20-50
Left lateral decubitus 4 0-18 21 4-50
Supine left flank 1 0-4 9 0-14

decubitus and supine left flank positions

were positive in only one instance. With
200-250 ml, all but the supine left flank
position had proved positive; and with
400-500 ml, this position became positive
in 4 of 5 cadavers. The approximate
amount of fluid introduced was recovered
at autopsy, confirming the fact that little
if any was present initially. The hand-
knee and right lateral decubitus positions
were the most sensitive in detecting small
quantities of fluid, while the left lateral
decubitus and supine left flank positions
were relatively insensitive. Only the right
lateral decubitus position was sensitive to
both small amounts and increasing incre-
ments of ascites (TABLE I; Fig. 3).
In 4 of the 14 cadavers, ascites was de-
tected by ultrasound; this was confirmed
by autopsies in all instances. The amount
of free intraperitoneal fluid found was 200,
500, 1,500 and 1,700 ml, respectively.
With 200 ml there was no evidence of
ascites in 4 of 5 pairs of positions. The
hand-knee position was not performed, due
to the cadaver's weight. In the cadaver
in which 500 ml was found, an average Fig. 4. Ultrasonic tracings in the five standard
pairs of positions demonstrate the typical patterns of
echo-free zone of 35 mm was obtained in fluid-filled loops of bowel (A) and ascites (B).
all positions. With 1,500 to 1,700 ml, the
echo-free space had increased to an average results. After the absence of ascites had
of 60 mm. The right lateral decubitus been established by ultrasonic studies,
position was apparently most sensitive to approximately 2 liters of water was intro-
volume change, going from 0 with 200 ml duced per rectum. A self-retaining balloon
to 45 mm with 500 ml and finally to an catheter was used to prevent the water
average of 125 mm with 1,500-1,700 ml. from escaping. Ultrasonic echo patterns
Experiments were carried out on 2 were again recorded in all five positions.
cadavers to determine whether the fluid- Two types of fluid patterns were obtained.
filled bowel would produce false-positive Along the flanks, a constant ultrasonic
20 B. B. GOLDBERG, G.
Initial
3 Weeks Later
Fig. 5. Ascites has cleared follow-
ing diuretic therapy. Upright trac-
ings obtained in the right lateral
decubitus position, with inverted trac-
ings obtained in the supine position.
fluid pattern which did not change with
movement of the cadaver was recorded;
this was found to be due to fluid in the
ascending and descending colon, which are
relatively fixed in position. The second
type of ultrasonic echo pattern was similar
to that seen with multicystic structures
(11, 12) and was noted particularly in the
hand-knee position, representing multiple
fluid-filled loops of bowel. This complex
cyst pattern changed slightly with changes
in position but still gave a characteristic
pattern different from that seen with free
intraperitoneal fluid (Fig. 4).
B. Clinical: Ultrasonic determina-
tions were carried out on 36 patients.
Seven showed no ultrasonic evidence of
Fig. 6. Left subdiaphragmatic abscess. The insert with a marker is a
localizing spot-film. Ultrasonic supine (A) and right lateral decubitus (B)
tracings show a typical fixed fluid pattern.
A. GOODMAN, AND H. R. CLEARFIELD July 1970
ascites, while 22 demonstrated a typical
free fluid pattern and the remaining 7
showed evidence of a fixed fluid pattern.
Of the 7 patients with negative ultra-
sonic readings, 3 had no evidence of ascites
at surgery and one had a negative
paracentesis. Of the 22 with positive
ultrasonic readings, 8 had little or no
clinical evidence of ascites. In none of
these 8 was the presence of ascites verified
by surgery or paracentesis, although 6
had clinical evidence of cirrhosis of the
liver. The remaining 14 patients showed
clinical and radiographic evidence of mod-
erate to massive ascites. Eleven had
clinical evidence of cirrhosis, 2 had car-
cinomatosis, and one had a nephrotic
syndrome. Two had a positive para-
centesis. Four others demonstrated as-
cites ranging from 2,000 to 9,500 ml at
surgery. With these large amounts of
fluid, there was only a rough correlation
between the size of the echo-free fluid
space and the actual amount of ascites
present.
Serial determinations were performed in
4 patients. In 2, the echo-free zone de-
creased after several liters of ascitic fluid
had been removed. In one of these pa-
tients, ultrasonic studies demonstrated
reaccumulation of fluid. In another, the
response to diuretic therapy was followed:
the patient, known to have cirrhosis, lost
20 lb. in two weeks, and the ultrasonic
fluid pattern and paracentesis became
Vol. 96 EVALUATION OF ASCITES BY ULTRASOUND
negative (Fig. 5). In the remaining
case, there was no evidence of ascites
initially, and this was confirmed at surgery
for chronic peptic ulcer disease. Two
weeks later, ascites was demonstrated by
ultrasonography and its presence proved
by paracentesis.
In , patients, fixed' ultrasonic fluid
patterns were obtained in localized areas.
Two patients demonstrated an enlarged
gallbladder in the right lateral decubitus
position alone, and the gallbladder was
found to be enlarged at surgery, with no
evidence of ascites. The remaining 5
patients had abscesses. Two of these
were subhepatic and 3 were subdiaphrag-
matic; of these 3, one was on the right and
2 were on the left. Four of the 5 were
proved at surgery. These and similar
fixed ultrasonic fluid patterns seen in vari-
ous fluid-filled masses were easily differ-
entiated from the echo pattern seen in
ascites (Fig. 6).
DISCUSSION
The skilled clinician generally has little
difficulty identifying moderate to large
amounts of free intra-abdominal fluid by
physical examination; however, lesser
quantities frequently escape detection.
It has been demonstrated experimentally
and clinically that ascites can easily be
detected by means of A-mode ultrasound.
The ability of ultrasonography to demon-
strate as little as 100 ml of free fluid is of
value in the early detection of ascites in
cirrhosis and malignancy. In addition,
when potent diuretic therapy is used in the
treatment of ascites, ultrasound will docu-
ment the point at which fluid has been
eliminated, thus helping to avoid the
hazards of overtreatment. The technique
will also prove useful in the demonstra-
tion of ascites in obese patients, in whom
physical examination is more difficult.
Of the positions used to make these mea-
surements, the hand-knee and right lateral
decubitus positions are the most sensitive,
perhaps because fluid trapped in the supine
position in the pelvis and the various ab-
dominal spaces flows toward the dependent
21
abdominal surface. The right lateral
decubitus position is more sensitive than
the left lateral decubitus position, since
the large volume occupied by the liver (as
compared to the spleen) decreases the
space available for free fluid. The right
lateral decubitus position was also found
to be most useful in evaluating increases
in the volume of ascitic fluid. The hand-
knee position was not as valuable in this
regard, for, as the amount of ascites in-
creases, the fluid apparently spreads out
over a larger area of the abdominal sur-
face rather than increasing in depth, ac-
counting for the lack of a proportional in-
crease in the echo-free zone with increas-
ing volume.
The use of multiple positions enabled us
to demonstrate changes in the ultrasonic
fluid pattern and thus differentiate be-
tween free and loculated fluid. The ma-
neuvers were of particular value when
confronted with an enlarged gallbladder
or abscess seen as a fixed echo-free zone.
Fluid-filled loops of bowel produced two
ultrasonic patterns, a complex ultrasonic
cyst pattern produced by multiple fluid-
filled loops of bowel, similar to that seen in
multicystic masses, and a fixed fluid ultra-
sonic pattern demonstrating no significant
change with a change in position, pro-
duced by the fixed portions of the colon.
In the severely ill or debilitated pa-
tient, it is often difficult to obtain a reading
in the hand-knee position. However,
readings can always be obtained in the
other positions. The ultrasonic equip-
ment is mobile and can easily be trans-
ported to the bedside. The examination is
completely atraumatic and can be per-
formed by a trained technician with
minimal time and expense.
Department of Radiology
Episcopal Hospital
Philadelphia, Penna. 19125
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