Chapter 044. Abdominal Swelling and Ascites (Part 3)

A gradient 97% accuracy and mandates a search for other causes such as peritoneal carcinomatosis, tuberculous peritonitis, pancreatitis, serositis, pyogenic peritonitis, and nephrotic syndrome (Table 44-1). Table 44-1 presents some of the disease states that produce high-SAAG and low-SAAG ascites. Although there is variability of the ascitic fluid in any given disease state, some features are sufficiently characteristic to suggest certain diagnostic possibilities. For example, blood-stained fluid with 25 g/L protein is unusual in uncomplicated cirrhosis but is consistent with tuberculous peritonitis or neoplasm. ...
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Chapter 044. Abdominal Swelling and Ascites (Part 3) Chapter 044. Abdominal Swelling and Ascites (Part 3) A gradient 97% accuracy and mandates a search for other causessuch as peritoneal carcinomatosis, tuberculous peritonitis, pancreatitis, serositis,pyogenic peritonitis, and nephrotic syndrome (Table 44-1). Table 44-1 presentssome of the disease states that produce high-SAAG and low-SAAG ascites.Although there is variability of the ascitic fluid in any given disease state, somefeatures are sufficiently characteristic to suggest certain diagnostic possibilities.For example, blood-stained fluid with >25 g/L protein is unusual in uncomplicatedcirrhosis but is consistent with tuberculous peritonitis or neoplasm. Cloudy fluidwith a predominance of polymorphonuclear cells (>250/µL) and a positive Gramsstain are characteristic of bacterial peritonitis, which requires antibiotic therapy; ifmost cells are lymphocytes, tuberculosis should be suspected. The completeexamination of each fluid is most important, for occasionally only one findingmay be abnormal. For example, if the fluid is a typical transudate but contains>250 white blood cells per microliter, the finding should be recognized as atypicalfor cirrhosis and should warrant a search for tumor or infection. This is especiallytrue in the evaluation of cirrhotic ascites where occult peritoneal infection may bepresent with only minor elevations in the white blood cell count of the peritonealfluid (300–500/µL). Since Grams stain of the fluid may be negative in a highproportion of such cases, careful culture of the peritoneal fluid is mandatory.Bedside inoculation of blood culture flasks with ascitic fluid results in adramatically increased incidence of positive cultures when bacterial infection ispresent (90 vs. 40% positivity with conventional cultures done by the laboratory).Direct visualization of the peritoneum (laparoscopy) may disclose peritonealdeposits of tumor, tuberculosis, or metastatic disease of the liver. Biopsies aretaken under direct vision, often adding to the diagnostic accuracy of the procedure. Table 44-1 Characteristics of Ascitic Fluid in Various Disease States Cond G Pro Se Cell Count Othition ross tein, g/L rum- er Tests Appeara Ascites Re White Albumin d Blood Blood Cells, nce Gradient Cells, per µL , g/dL >10,000/µ L Cirrh St 1 1% 25 1000 Cytasm raw- (75%) .1 % (50%); ology, cell colored, variable cell block, hemorrha types peritoneal gic, biopsy mucinous , or chylous Tuber Cl >25 1000 Periculous ear, (70%); tonealperitonitis turbid, (50%) .1 usually >70% biopsy, hemorrha lymphocytes stain and gic, culture for chylous acid-fast bacilli Pyoge Tu If or extraction, chylous Sudan staining Pancr Tu Var 25 be blood- amylase inpseudocyst) gic, or stained ascitic chylous fluid and serum a Because the conditions of examining fluid and selecting patients were notidentical in each series, the percentage figures (i ...