EUH Morning Report: What is the rational clinical exam for ascites?

The Bottom Line: The examiner should ask about recent ankle edema, weight gain, or change in abdominal girth. Other potentially important items are a history of liver disease or congestive heart failure. The focused physical exam includes: (1) inspection for bulging flanks, (2) percussion for flank dullness, (3) a test for shifting dullness, and (4) a test for a fluid wave (Williams and Simel, 1992).


References: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116330, Ascites; [updated 2017 Jul 31, cited 2018 Jun 22]; [about 20 screens]. Emory login required.

Williams JW Jr, Simel DL. The rational clinical examination. Does this patient have ascites? How to divine fluid in the abdomen. JAMA. 1992 May 20;267(19):2645-8.

Summary: Ascites is a symptom that may have important diagnostic, prognostic, and therapeutic implications. When clinically detectable, ascites may indicate underlying heart failure, liver disease, nephrotic syndrome, or malignancy (Williams & Simel, 1992).

Skin: assess for signs of liver disease

  • Jaundice
  • Spider veins
  • Palmar erythema
  • Caput medusa (abdominal wall collateral veins)


  • Jugular venous distention may be present secondary to heart failure


  • Look for associated pleural effusions (dependent rales)


  • Abdominal distention
  • Fluid wave
  • Shifting dullness
  • Umbilicus eversion
  • Low umbilicus position (Tanyol sign)
  • Flank dullness
    • About 1,500 mL of fluid must be present to be detected
    • If no flank dullness, patient has < 10% chance of ascites


  • Look for associated peripheral edema
  • Leukonychia (white nails) may be seen in advanced liver disease


  • Penile or scrotal edema may be seen

(DyanMed Plus, 2018)