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ascitic fluid analysis

Analysis of peritoneal fluid obtained from paracentesis Indications: ascites of unknown etiology Procedure: 1) cell count a) WBC > 250/mm3 with neutrophils & bands suggests bacterial peritonitis b) lymphocytic predominance occurs in tuberculous peritonitis & peritoneal carcinomatosis c) correct cell count for RBC, use RBC/WBC ratio from CBC 2) ascitic fluid protein a) < 1.0 g/dL suggests high risk for spontaneous bacterial peritonitis [3] b) total protein is low <2.5 g/dL in cirrhotic ascites & high >= 2.5 g/dL in cardiac ascites [3] 3) albumin a) [serum albumin] - [ascitic fluid albumin] > 1.1 g/dL is consistent with portal hypertension - hepatic cirrhosis - liver metastasis - hepatic failure - alcoholic hepatitis - Budd-Chiari syndrome - right heart failure or constrictive pericarditis - ascitic fluid total protein > 2.5 g/dL [3] - portal vein thrombosis (portal hypertension) - myxedema - fatty liver of pregnancy - hepatic veno-occlusive disease b) [serum albumin] - [ascitic fluid albumin] < 1.1 g/dL - peritoneal carcinomatosis - biliary ascites - tuberculous ascites - pancreatitis - nephrotic syndrome - bowel obstruction with infarct - postoperative lymphatic leakage - serositis seen in connective tissue disease - less useful in patients with known hepatic cirrhosis [2] 4) culture a) most bacterial peritonitis is caused by a single organism b) anaerobic & aerobic cultures 5) amylase a) increased ascitic fluid amylase with pancreatitis & bowel perforation b) levels generally 3-5 times serum levels 6) tuberculosis testing a) tuberculous peritonitis is often associated with negative cultures from ascitic fluid b) predominance of mononuclear cells in ascitic fluid c) laparoscopy with histologic analysis of biopsy specimens is more sensitive for tuberculous peritonitis 7) cytology - less sensitive where tumor cells do not line the peritoneal cavity, i.e. lymphoma, hepatoma 8) triglycerides when cloudy fluid suggests chylous ascites 9) bilirubin > 6 mg/dL & > [serum bilirubin] suggests biliary or upper GI perforation

Related

ascites paracentesis

General

chemistry panel hematology panel microbiology panel

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 367-68
  2. Khandwalla HE et al The utility of evaluating low serum albumin gradient ascites in patients with cirrhosis. Am J Gastroenterol 2009 Jun; 104:1401. PMID: 19491852
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 19 American College of Physicians, Philadelphia 2006, 2009, 2012, 2021