3. Appearance Interpretation
Clear Uncomplicated ascites in the setting of cirrhosis is usually
translucent
Yellow
Turbid or cloudy Spontaneously infected
Milky
"chylous
ascites"
Milky fluid usually has a triglyceride concentration greater than
serum
and greater than 200 mg/dL (2.26 mmol/L) and often greater than
1000
mg/dL (11.3 mmol/L).
Cirrhosis ,abdominal malignancy & lymphatic abnormalities.
Pink or bloody (RBC of
>10,000/mm3)
"traumatic tap“, or malignancy
Brown Deeply jaundiced patients have brown ascitic fluid with a bilirubin
concentration approximately 40 percent of the serum value.
If the ascitic fluid is as brown as molasses and the bilirubin
concentration
is greater than the serum value, the patient probably has a
ruptured
gallbladder or perforated duodenal ulcer
4. Diagnosis:
established with a combination of a physical
examination & an imaging test (USG).
Approx 1500 mL of fluid had to be present for flank
dullness to be detected
Lesser degrees of ascites can be missed.
Ultrasonography can be helpful when the physical
examination is not definitive
5. Ascites can be classified based on the underlying
pathophysiology:
Portal hypertension
› Cirrhosis, Alcoholic hepatitis
› Acute liver
› Hepatic veno-occlusive disease
› Heart failure
› Constrictive pericarditis
› Hemodialysis-associated ascites (nephrogenic
ascites)
11. The cell count with differential is the single most
helpful test performed on ascitic fluid to evaluate for
infection.
Polymorphonuclear count ≥ 250/mm3
› spontaneous bacterial peritonitis.
In bloody ascites:
› one neutrophil should be subtracted from the
absolute neutrophil count for every 250 red cells to
yield the "corrected neutrophil count“.
12. The serum-to-ascites albumin gradient (SAAG) accurately
identifies the presence of portal hypertension and is more
useful than the protein based exudate/transudate concept.
SAAG
› Serum albumin value - ascitic fluid albumin
› (obtained on the same day).
SAAG ≥ 1.1 g/dL (11 g/L)
› Indicates portal hypertension
› (Budd-Chiari syndrome, heart failure, or liver cirrhosis)
SAAG <1.1 g/dL (<11 g/L)
› Indicates that the patient does not have portal hypertension
13. Protein — Ascitic fluid had been classified as an
exudate if the total protein concentration is ≥2.5 or 3
g/dL and
A transudate if it is below this cut-off.
However, the exudate/transudate system of ascitic
fluid classification has been replaced by the SAAG.
Measurement of total protein, glucose, and lactate
dehydrogenase (LDH) in ascites may also be of
value in distinguishing SBP from gut perforation into
ascites
14. Patients with ascitic fluid that has a neutrophil count
≥250 cells/mm3 and meets two out of the following
three criteria are unlikely to have SBP and warrant
immediate evaluation to determine if gut perforation
into ascites has occurred.
› Total protein >1 g/dL
› Glucose <50 mg/dL (2.8 mmol/L)
› LDH greater than the upper limit of normal for
serum.
› Bilirubin concentration should be measured in
patients with brown ascites
15. Condition Glucose
Uncomplicated cirrhotic ascites Similar to serum glucose
Peritoneal carcinoma Low
Gut perforation May be undetectable
Condition LDH Ascitic fluid/Serum (AF/S ratio)
Uncomplicated cirrhotic
Ascites
0.4
Infection or tumor More than 1.0
Condition Ascitic Amylase AF/S ratio of amylase
Uncomplicated
cirrhotic ascites
40 IU/L 0.4
pancreatitis or gut
perforation
↑ ↑
Pancreatic ascites ↑↑↑ (2000 IU/L) ↑↑↑ ( 6.0)
16. Adenosine deaminase
› Adenosine deaminase activity of ascitic fluid has
been proposed as a useful non-culture method of
detecting tuberculous peritonitis; however,
patients with cirrhosis and tuberculous peritonitis
usually have falsely low values .
