Puddle sign... What's that?

Puddle is a small pool of fluid.


Similarly Puddle sign is found when a pool of fluid gets accumulated in the peritoneal cavity (ASCITES).

This auscultatory sign can successfully detect as less as 120 ml of  free fluid in the abdomen.



 On the other hand the two signs of percussion and palpation, namely shifting dullness and fluid thrill are elucited when the peritoneal fluid volume is more than 500 ml and 1500 ml respectively.

"Like the silence before the storm, there is dullness before the thrill."

Let us presume that we have a patient with ascites and we are required to perform a diagnostic paracentesis (25ml fluid withdrawn using 5ml syringe). What are we required to look at?

  1. Color:

    Clear or cloudy yellow    : Normal/TB

    Straw colored    : Cirrhosis, Cancer (Ca), CHF, Nephrotic syndrome

    Bloody    : Ca, TB, Pancreatic (Contain RBCs)

    Milky (Chylous)    : Nephrosis, Pancreatic

    Dark brown: Cirrhosis
  2. SAAG (Serum to ascites Albumin to Gradient):

    >1.1 g/dl is Exudate    :
    Ca
    Peritonitis
    Pancreatitis
    Vasculitis
    Nephrotic Syndrome

    <1.1 g/dl is Transudate    :
    Cirrhosis
    Alcoholic Hepatitis
    Congestive Heart Failure
    Budd-Chiari syndrome
    Myxedema
    Constrictive Pericarditis
  3. Amylase: An increased amylase level indicates damaged pancreas.  

            After determining the cause, along with treating the disease, managing ascites in essential.
            Management of ascites is as follows:
            1. No clinical features, ascites diagnosed by ultrasound: Salt restriction
            2. Clinical features present without respiratory system involvement: Salt restriction + diuretics
              Diurectics: Spironolactone (Max dose: 400mg/day) or Furosemide (Max dose: 160mg/day)
            3. Clinical features with respiratory system involvement: Paracentesis + IV Albumin

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