From the Guidelines
The puddles sign is a less reliable clinical sign for detecting ascites, with lower sensitivity and specificity compared to shifting dullness, and is not a recommended primary method for diagnosis. When evaluating a patient for ascites, the physical examination should prioritize percussion of the flanks to assess for shifting dullness, which has an 83% sensitivity and 56% specificity in detecting ascites 1. The puddles sign, along with the fluid wave, is considered cumbersome and performs less well than shifting dullness in detecting ascites. Key points to consider in the diagnosis of ascites include:
- The presence of a full, bulging abdomen should lead to percussion of the flanks to assess for shifting dullness
- Approximately 1500 mL of fluid must be present before flank dullness is detected
- If no flank dullness is present, the patient has less than a 10% chance of having ascites
- Abdominal ultrasound may be required to determine with certainty if fluid is present, especially in obese patients
- The diagnosis of new-onset ascites is usually confirmed by successful abdominal paracentesis and/or ultrasound 1. In clinical practice, relying on the most sensitive and specific methods for diagnosing ascites is crucial for timely and effective management, and the puddles sign is not a primary recommended method due to its lower performance compared to shifting dullness.
From the Research
Clinical Significance of the Puddles Sign
The puddles sign is a clinical sign that is not directly mentioned in the provided studies. However, the studies discuss the diagnosis and management of ascites, which is the accumulation of fluid in the peritoneal cavity.
Diagnosis of Ascites
- Ascites can be diagnosed through abdominal paracentesis with ascitic fluid analysis 2, 3
- The serum-ascites albumin gradient (SAAG) is a useful indicator of portal hypertension 4, 2
- Ascitic fluid analysis should include total protein concentration, cell count and differential, and optional tests such as cholesterol, fluid culture, and cytology 2
Management of Ascites
- Sodium restriction and diuretics are the cornerstone of ascites management 4
- Repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts may be necessary for patients who are refractory to medical treatment 4
- Bioimpedance spectroscopy (BIS) may aid in fluid status assessment in patients with liver cirrhosis, but its use is not well established 5
Limitations of the Studies
- The studies do not provide direct evidence for the significance of the puddles sign as a clinical sign.
- The studies focus on the diagnosis and management of ascites, rather than the puddles sign specifically.