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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : -9 مورد

Evaluation of ascites of uncertain etiology

Evaluation of ascites of uncertain etiology
Perform the following studies:
  • Diagnostic paracentesis*
  • Serum albumin
  • Abdominal imaging (eg, transabdominal ultrasound, computed tomography scan)
Calculate SAAG
Determine likely etiology:
Diagnosis Fluid cell count Fluid total protein Fluid triglyceride level Fluid cytology Other testing
SAAG ≥1.1 g/dL
Cardiac ascites (eg, heart failure) Neutrophil count <250 cells/microL ≥2.5 g/dL Normal Negative
  • Evaluate with echocardiogram and chest radiograph
Cirrhosis and portal hypertension Neutrophil count <250 cells/microL <2.5 g/dL Normal Negative
  • Ultrasound may show small, nodular liver
Cirrhosis with portal hypertension complicated by SBPΔ Neutrophil count ≥250 cells/microL <2.5 g/dL Normal Negative
  • If the fluid culture is positive, a single organism is usually isolated
  • Some patients have a negative ascitic fluid culture
SAAG <1.1 g/dL
Chylous ascites◊ WBC count ≥500 cells/microL with predominantly lymphocytes Variable Elevated, typically >200 mg/dL Variable
  • Imaging may show abdominal lymphadenopathy if malignancy-related
Nephrotic syndrome Neutrophil count <250 cells/microL <2.5 g/dL Normal Negative
  • Elevated 24-hour urine protein excretion
Pancreatic ascites Variable§ >3 g/dL Normal Negative
  • Ascitic fluid amylase >1000 units/L
  • Imaging may show pancreatitis and/or pancreatic fluid collection
Peritoneal carcinomatosis¥ WBC count ≥500 cells/microL with predominantly lymphocytes ≥2.5 g/dL Normal Positive‡
  • Imaging shows peritoneal and omental implants
Tuberculous peritonitis¥ WBC count ≥150 cells/microL with predominantly lymphocytes >3 g/dL Normal Negative
  • Peritoneal biopsy to evaluate for Mycobacterium tuberculosis
  • Elevated ascites adenosine deaminase level
For additional details, refer to UpToDate content on the evaluation and management of ascites and on the management of the underlying conditions.

LDH: lactate dehyrogenase; SAAG: serum-ascites albumin gradient; SBP: spontaneous bacterial peritonitis; WBC: white blood cell.

* The following tests are routinely performed on ascitic fluid: cell count, differential, albumin, and total protein. Selecting additional tests is informed by clinical findings. As examples, if the fluid appears milky, we obtain trigylceride level. If malignancy is suspected, we obtain fluid cytology. If infection is suspected, we obtain Gram stain, culture, and glucose level. If pancreatic disease is suspected, we obtain amylase.

¶ The SAAG is calculated by subtracting the ascitic fluid albumin value (in g/dL) from the serum albumin value (in g/dL).

Δ Secondary bacterial peritonitis is less common than SBP and is suspected in patients with bile-stained ascites with elevated ascitic fluid total protein, elevated LDH and/or low glucose. Imaging may show a perforated viscus or infectious process involving an abdominal organ. SAAG in secondary bacterial peritonitis is variable. Refer to UpToDate content on differentiating secondary bacterial peritonitis from SBP for details.

◊ Chylous ascites has a milky appearance. Laboratory features of chylous ascites may vary depending on the underlying cause. As examples, chylous ascites may be related to lymphatic abnormalities, abdominal malignancy, or infection. Refer to UpToDate content on chylous ascites for details.

§ In pancreatic ascites, the neutrophil count may be low or may be ≥250 cells/microL if the ascitic fluid is infected.

¥ Patients with peritoneal disease who also have underlying cirrhosis and/or portal hypertension may have SAAG ≥1.1.

‡ For patients with suspected peritoneal carcinomatosis (eg, based on imaging findings) but with negative initial fluid cytology, repeat paracentesis with fluid cytology is warranted.

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