Evaluation of the patient with suspected malignancy-related ascites

Select the target population: Patients with ascites and suspected or established malignancy*
Perform the following studies: Diagnostic paracentesis^¶^Δ Serum albumin Abdominal imaging (eg, computed tomography scan, magnetic resonance imaging)
Determine likely etiology for ascites:
Diagnosis	Fluid cell count^◊	Fluid total protein	High fluid triglyceride level^§	Fluid cytology	Imaging features
SAAG <1.1 g/dL^¥
Peritoneal carcinomatosis	High with predominantly lymphocytes	≥2.5 g/dL	No	Positive^‡	Peritoneal and omental implants
Malignancy-related chylous ascites	High with predominantly lymphocytes	≥2.5 g/dL	Yes	Negative	Abdominal lymphadenopathy
SAAG ≥1.1 g/dL^¥
Massive liver metastases with portal hypertension	Low	<2.5 g/dL	No	Negative	>50% liver replacement by tumor
Hepatocellular carcinoma with cirrhosis	Low	<2.5 g/dL	No	Negative	Focal lesion(s) in cirrhotic liver^†
Malignancy-related Budd-Chiari syndrome	Low	Variable	No	Negative	Extrinsic tumor compression causing narrowing and/or thrombus of the hepatic vein

Refer to UpToDate content on the evaluation and management of malignancy-related ascites.

SAAG: serum-to-ascites albumin gradient.
* Ascites typically develops in the setting of recurrent and/or advanced cancer. Malignancies of ovarian and urinary bladder origin tend to cause isolated peritoneal carcinomatosis without liver metastases. The most common tumor types causing peritoneal carcinomatosis with liver metastases are colon, gastric, breast, pancreatic, and lung cancers.
¶ The following tests are routinely performed on ascitic fluid when malignancy-related ascites is suspected: Gram stain, aerobic and anaerobic culture, cell count and differential, albumin, total protein, glucose, triglyceride level, cytology.
Δ For patients with suspected malignancy-related ascites, diagnostic paracentesis is performed if it will contribute to the evaluation and/or management.
◊ A high ascitic fluid white blood cell count is defined as ≥500 cells/mm³.
§ For patients with chylous ascites, fluid triglyceride level is typically above 200 mg/dL.
¥ The SAAG is calculated by subtracting the ascitic fluid albumin value (in g/dL) from the serum albumin value (in g/dL).
‡ For patients with suspected peritoneal carcinomatosis (eg, based on imaging findings) but with negative initial fluid cytology, repeat paracentesis with fluid cytology is warranted.
† For patients at risk for developing hepatocellular carcinoma (eg, those with cirrhosis), the diagnosis can be made with contrast-enhanced computed tomography or magnetic resonance imaging tailored for liver evaluation. Refer to other UpToDate content on diagnosis of hepatocellular carcinoma.

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Evaluation of the patient with suspected malignancy-related ascites