Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

Ascites 163

➣SAAG≥1.1 gm/dL (high gradient)=portal hypertension

➣SAAG≤1.1 gm/dL (low gradient)=absence of portal hyperten-

sion

■Ascitic fluid total protein (AFTP):

➣AFTP >2.5 gm/dL in 20% of uncomplicated ascites

➣DDx of high AFTP: peritoneal carcinomatosis, tuberculous peri-

tonitis, cardiac ascites, Budd-Chiari syndrome, myxedema, bil-

iary ascites, & pancreatic ascites

■Culture:

➣Results optimized by bedside inoculation of 10 mL of ascitic fluid

into each of two culture bottles

Optional Tests

■Glucose: may drop to 0.0 mg/dL in gut perforation

■LDH:

➣Pts w/ neutrocytic ascites & 2 of following 3 ascitic fluid findings

may have surgical peritonitis:

➣Total protein >1.0 gm/dL

➣Glucose <50 mg/dL

➣LDH >upper limit of normal for serum

■Amylase:

➣Amylase in uncomplicated ascites less than half of serum

➣Ascitic fluid amylase level averages 2000 IU/L in pancreatic

ascites

■Triglyceride:=200 mg/dL & usually >1000 mg/dL in chylous ascites

■Cytology:

➣Positive only in peritoneal carcinomatosis

➣Negative in hepatocellular carcinoma, massive liver metastases,

or lymphoma w/o peritoneal metastases

differential diagnosis

■High SAAG ascites: cirrhosis, alcoholic hepatitis, hepatocellular car-

cinoma, massive liver metastases, fulminant hepatic failure, cardiac

ascites, myxedema, Budd-Chiari syndrome, portal vein thrombosis,

veno-occlusive disease of liver, acute fatty liver of pregnancy, mixed

ascites

■Low SAAG ascites: peritoneal carcinomatosis, tuberculous peritoni-

tis, pancreatic ascites, biliary ascites, peritonitis from connective tis-

sue disease, bowel infarction or perforation