Abdominal paracentesis - Chọc dò màng bụng

Chọc dịch màng bụng

1. ABDOMINAL PARACENTESIS
PHUNG HUY HOANG, MD
Resident in Internal Medicine
Pham Ngoc Thach University of Medicine
June, 2017

2. Floch M. H. (2009), "Netter's Gastroenterology",Saunders

3. •Most rapid and cost-effective method of diagnosing the
cause of ascites
•The only method of detecting ascitic fluid infection
INDICATIONS
•Allinpatients+outpatientswithnew-onsetascites
•Allpatientswithascitesadmittedtothehospital
•Patients(whetherhospitalizedornot)inwhomsymptoms,signs,orlaboratoryabnormalities
suggestiveofinfectiondevelop
•Therapeuticparacentesis
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3

4. Anstee Q. M., Jones D. E. J. (2014), Davidson's Principles and Practice of
Medicines, Brian R. Walker, et al., Editors, Churchill Livingstone, Elsevier, pp.
921-942

5. CONTRAINDICATIONS
•Coagulopathy:clinicallyevidenthyperfibrinolysis(three-dimensionalecchymosis/hematoma)
orDIC
•Mildtomoderatecoagulopathy:acceptable
•Overallcoagulation:usuallynormal/cirrhosisdespiteabnormaltestsofcoagulation
balanceddefciencyofprocoagulantsandanticoagulants
•Cut-offvaluesforcoagulationparameters(paracentesisavoided):nodata
•Transfusionofbloodproductsroutinelybeforeparacentesisinpatientswithcirrhosis
andcoagulopathy:nodata
•Localinfectionoverlyingthepuncturesite
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A. (1986), Archives of Internal Medicine, 146 (11), pp. 2259-2261

6. COMPLICATIONS
•Abdominalwallhematoma(2%)
•Breakageofaplasticcatheterintotheperitoneumusemetalneedle
•Complicationrateshigher:inexperiencedoperator
•Nodeaths,infections,hemoperitoneumorentryoftheparacentesisneedleintothebowelbeen
report
•Diagnosticparacentesis:safewithaverylowincidenceofseriouscomplications(particularly
whencomparedtotherapeuticparacentesis)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3
De Gottardi A., Thévenot T., Spahr L., et al. (2009), Clinical Gastroenterology and Hepatology, 7 (8), pp. 906-909

7. “Inoneseriestheinternationalnormalizedratio(INR)wasashighas8.7andtheplateletcountwas
aslowas19,000cells/mm3,yetnoonehadableedingcomplicationandnoonereceived
transfusionsofbloodproductsbeforeorafterparacentesis”
Grabau C. M., Crago S. F., Hoff L. K., et al. (2004), "Performance standards for therapeutic abdominal paracentesis", Hepatology, 40 (2), pp. 484-488

8. PATIENT’S POSITION
•Volumeoffluidintheabdomen,thicknessoftheabdominalwall
•Largevolume,thinabdominalwall:supineposition,headofbedelevatedslightly
•Lessfluid:lateraldecubitusposition,tappedinthemidlineorrightorleftlowerquadrant
•Smallamountsoffluid:face-downpositionorwithUSguidance
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Sakai H., Sheer T. A., Mendler M. H., et al. (2005), Liver Int, 25 (5), pp. 984-6

9. ENTRY SITE
•Leftlowerquadrant(morepreferred)
•Rightlowerquadrant(lesspreferredcecumdistendedwithgasfromlactulosetherapy,more
likelytohaveasurgicalscarboweladherentappendectomyscarprecludes)
•Midlinesite:avascular(longmidlinescarprecludes,obesepatients:abdominalwallusually
thickerinthemidline>lowerquadrants)
•USguidance:smallamount,multiplescars
•Avoid:scars,abdominalwallcollaterals,areaoftheinferiorhypogastricartery(midwaybetween
anteriorsuperioriliacspineandpubictubercle)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Sakai H., Sheer T. A., Mendler M. H., et al. (2005), Liver Int, 25 (5), pp. 984-6
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3

10. 2fngerbreadths (3cm) cephalad and 2
fngerbreadths medial to the
anterior superior iliac spine
“Alaparoscopicstudyfoundthatcollateralscanbepresentinthemidlineandthuspresenta
riskorruptureduringparacentesis”
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3
Oelsner D. H., Caldwell S. H., Coles M., et al. (1998), Gastrointestinal Endoscopy, 47 (5), pp. 388-390

11. CHOICE OF NEEDLE
•Standardmetal22-gaugeneedle(1.5inchesfornotoverweight,3.5inchesforobese)
•Smallergaugenumbersindicatelargerouterdiameters
•Metalneedles:
•preferabletoplastic-sheathedcannulas(plasticsheathsmayshearoffintotheperitoneal
cavity,potentialtokinkandobstructtheflowoffluidafterthecannulaisremoved)
•notpuncturethebowel(unlessthebowelisadherenttoascarorseveregaseousdistentionis
present)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Sakai H., Sheer T. A., Mendler M. H., et al. (2005), Liver Int, 25 (5), pp. 984-6

12. TECHNIQUE
1.Dianosticparacentesis
2.Therapeuticparacentesis
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate

13. TECHNIQUE
PREPARATION
•Drapes,gown,hat,mask:optional
•Sterilegloves:shouldbeused(asciticfluidculturesfrequentlygrowskincontaminants)
•Skindisinfection:iodinesolution
•Skinandsubcutaneoustissue:localanesthetic
•Sterilepackage(gloves):sterilefeld(toplacesyringes,needles,gauze,andothersupplies)
•Ensurethepatienthasanemptybladderpriortotheprocedure
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Patel N., Knight D. (2009), Clinical Practical Procedures for Junior Doctors, Mark Palazzo, Editor, Churchill Livingstone Elsevier, pp. 129-140
Diagnosis
(1)

14. TECHNIQUE
“ZTRACT”TECHNIQUE
•Preventleakageoffluidaftertheneedleiswithdrawn(Iftheneedlewereinsertedstraight
fluidwouldleakouteasilybecausethepathway:straight)
•Notinvolvemanipulatingtheneedleupanddown(leadtotissueinjury)
•Displacingtheskin~2cmdownwardslowlyinsertingtheparacentesisneedlemountedon
thesyringeheldintheotherhand(90
o
toskin)stabilizesthesyringe+retractsitsplunger
simultaneously
•Ifcertainthatneedletipisinsertedfarenoughbutnofluidisapparenttwistsyringe+needle
90degrees(topiercetheperitoneum)
•Theskinisreleased:onlyaftertheneedlehaspenetratedtheperitoneumandfluidflows
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Diagnosis
(2)

15. Patel N., Knight D. (2009), Clinical Practical Procedures for Junior Doctors, Mark Palazzo, Editor, Churchill
Livingstone Elsevier, pp. 129-140

16. Patel N., Knight D. (2009), Clinical Practical Procedures for Junior Doctors, Mark Palazzo, Editor, Churchill Livingstone Elsevier, pp. 129-140

17. Wong C. L., Holroyd-Leduc J., Thorpe K. E., et al. (2008), JAMA, 299 (10), pp. 1166-1178
“Z tract” technique

18. TECHNIQUE
•Slowlyinsertingtheparacentesisneedle:
•allowstheoperatortoseebloodifavesselisentered
•allowstheboweltomoveawayfromtheneedle
•allowstimefortheelasticperitoneumto“tent”overtheendoftheneedleandbepierced
•Syringeshouldbeaspiratedintermittentlyduringinsertion/5mm(continuoussuction
boweloromentummaybedrawntotheendoftheneedleoccludingflowunsuccessfultap)
•Mostcommoncauseofunsuccesful:
•continuousaspirationduringinsertionoftheneedle
•rapidinsertionandwithdrawaloftheneedlebeforetheperitoneumispierced
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Diagnosis
(3)

19. TECHNIQUE
•Larger-boreneedle(16-to18-gaugeneedle)andadditionalequipment
•Unlesstheneedleisallowedtodriftsubcutaneously,theneedle(orbluntsteelcannula)canbe
leftintheabdomenduringatherapeuticparacentesiswithoutinjury
•Larger-boreneedlesorcannulas:permitmorerapidremovaloffluidbutleavelargerdefects(if
theyentervesselsorthebowelinadvertently)
•Ensurewhenwithdrawingthetrocar:notwithdrawittooquickly(otherwisethedrainwillkink)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Patel N., Knight D. (2009), Clinical Practical Procedures for Junior Doctors, Mark Palazzo, Editor, Churchill Livingstone Elsevier, pp. 129-140
Therapeutic
(1)

20. Patel N., Knight D. (2009), Clinical Practical Procedures for Junior Doctors, Mark
Palazzo, Editor, Churchill Livingstone Elsevier, pp. 129-140

21. TECHNIQUE
•Withrespiratorymovementneedlemaygraduallyworkitswayoutoftheperitonealcavity
andintothesofttissuesomeserosanguineousfluidmayappearintheneedlehubortubing
•Thepumpshouldbeturnedofforaclampplacedonthetubing
•Thetubingshouldberemovedfromtheneedleandtheneedletwistedafewdegrees
•IfflowdoesnotresumeneedleshouldbetwistedabitmoreIfflowstilldoesnotresume
theneedleshouldbeinsertedin1-to2-mmincrementsuntilbriskdrippingoffluidfromthe
needlehubisseen
•Excessivemanipulationoftheneedle:avoided(minimizetheriskoftraumatothebowelor
bloodvessels)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Therapeutic
(2)

22. TECHNIQUE
•Asthefluidisremovedbowelandomentumdrawclosertotheneedleblocktheflow
ofasciticfluid
•Patientmustthenberepositioned(gravitycausesthefluidtopoolneartheneedle)
maximizetheamountoffluidremoved
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
BA R. (2012), UpToDate
Therapeutic
(3)

23. ASCITIC FLUID ANALYSIS
PHUNG HUY HOANG, MD
Resident in Internal Medicine
Pham Ngoc Thach University of Medicine
June, 2017

24. Cesario K. B., Choure A., Carey W. D. Cirrhotic Ascites. 2013 [cited 2017 June]

25. GROSS APPEARANCE
(1)
•Theopacityofmanycloudyasciticfluidspecimens:neutrophilsshimmeringeffect:glass
tubecontainingthefluidisrockedbackandforthinfrontofalight
•Transparentandusuallyslightlyyellow:Non-neutrocytic(i.e.,asciticfluid
polymorphonuclearneutrophil[PMN]count<250/mm
3
)
•Nearlyclear:absoluteneutrophilcount<1000/mm
3
•Quitecloudy:>5000/mm
3
•Franklypurulent:>50000/mm
3
(grossintraabdominalinfectione.gsecondaryperitonitisoran
abscess)diferrentialmilkyfluid!LackofodorandTG>200mg/dL:chylousascites
•Nopigmentandlooklikewater:verylowproteinconcentration
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106

26. •Thresholdforapinkappearance:RBCcountof10000/mm
3
•Distinctlyred:>20000/mm
3
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Fuidspecimens:bloody
•Traumatictap(blood-streaked,frequentlyclotunlessthefluidistransferred
immediatelytotheanticoagulant-containingtubeforthecellcount)
•Nontraumatic(bloodyhepaticlymph/portalhypertension,malignancy,TB/rare)or
remotelytraumaticblood-tingedasciticfluid:homogeneousandnotclot(already
clottedandtheclothaslysed)
GROSS APPEARANCE
(2)

27. •Asciticfluidfrequentlyislipid-laden,lipidopacifesthefluid
•Mostopaque,milkyfluidsamples(chylousascite):TG(triglyceride)>200mg/dL(2.26
mmol/L)andusually>1000mg/dL(11.30mmol/L)creamylayerwillseparate
•Diluteskimmilk:TG=100-200mg/dL(1.13-2.26mmol/L)
•Dark-brownfluid(withabilirubinconcentration>serum):biliaryperforation(Deeply
jaundicedpatients:bile-stainedasciticfluid,butlevelandthedegreeofpigmentation<serum)
•Tea-coloredtojetblack:Pancreaticascites:maybepigmented(effectofpancreaticenzymes
onRBCs)
•Blackasciticfluid:malignantmelanoma
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A. (1987), J Clin Gastroenterol, 9 (5), pp. 543-5
GROSS APPEARANCE
(3)

28. Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576

29. Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark
Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-
1576

30. CELL COUNT
(1)
•TheWBCcountinuncomplicatedascites/cirrhosis:usually<500/mm3
•ULNforabsolutePMNcountinuncomplicatedasciticfluid/cirrhosis<250/mm3
•AnyinflammatoryprocesscanresultinanelevatedasciticfluidWBCcount:
•Spontaneousbacterialperitonitis(SPB):mostcommonpredominantPMN
•Tuberculousperitonitisandperitonealcarcinomatosispredominantlymphocytes
•Leakageofbloodintotheperitonealcavity(slightlytraumatictap):asciticfluidWBC,
PMNcount(neutrophilspredominateinblood)correctedPMN/ascitefluid
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
1 PMN is subtracted from the absolute ascitic fluid PMN count for every 250 RBCs

31. •Duringdiuresis/cirrhosisandascites:WBCcountcanconcentrateto>1000/mm3requires
prediuresiscount,normallymphocytespredominate,unexplainedclinicalsymptomsorsigns
(e.g.,feverorabdominalpain)beabsent
•ShortsurvivalofPMNs:relativestabilityoftheabsolutePMNcountduringdiuresis
cutoffvalueremainsreliable
•SomelaboratoriescountmesothelialcellsinadditiontoWBCsandlabelthesumas
“nucleatedcells”
•Malignancy-relatedascitesmayalsoPMNcount(16%ofcasesinoneseries)(dyingtumor
cellsattractneutrophils),predominanceoflymphocytes
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.
CELL COUNT
(2)

32. SERUM-ASCITES ALBUMIN GRADIENT (SAAG)
(1)
•Beforethe1980s:totalproteintoclassifyascitesaseitherexudativeortransudative(cut-off2.5
g/dL[25g/L])notcarefuldefinedandvalidated.
•Theserum-ascitesalbumingradient(SAAG):provedtocategorizeascitesbetter,reflection
ofhepaticsinusoidalpressure
•SAAG:notexplainthepathogenesisofascitesformation,nordoesitexplainwherethe
albumincamefrom(liverorbowel)
•Oncotic-hydrostaticbalance(Starlingforces),differencebetweentheserumandasciticfluid
albuminconcentrationscorrelatesdirectlywithportalpressure.
•Theaccuracyofthetestisexcellent(evenwithasciticfluidinfection,diuresis,therapeutic
paracentesis,IVinfusionsofalbumin,andvariouscausesofliverdisease)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A., Montano A. A., Akriviadis E. A., et al. (1992), Ann Intern Med, 117 (3), pp. 215-20.

33. Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.

34. •SAAG=serumalbumin-asciticalbumin
•≥1.1g/dL(11g/L)=highalbumingradient:portalhypertension
•<1.1g/dL(11g/L)=lowalbumingradient:unlikelytohaveportalhypertension
•Ifthefrstresultisborderline(e.g.,1.0or1.1g/dL[10or11g/L])repeatingthe
paracentesisandanalysisusuallyprovidesadefinitiveresult
•SAAGcorrelatesverywellwiththehepaticvenouspressuregradient(r=0.72)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Hoefs J. C. (1983), J Lab Clin Med, 102 (2), pp. 260-73
SERUM-ASCITES ALBUMIN GRADIENT (SAAG)
(2)

35. FALSEVALUE
(1)
•TheaccuracyoftheSAAGreduced:specimensofserumandascitesarenotobtainednearly
simultaneously(shouldbesameday,preferablysamehour).
•Bothserumandasciticfluidalbuminconcentrationschangeovertime;howeverparallel
differenceisstable.
•Arterialhypotension:portalpressureandanarrowingoftheSAAG.
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
SERUM-ASCITES ALBUMIN GRADIENT (SAAG)
(3)

36. FALSEVALUE
(2)
•Lipidinterfereswiththeassayforalbumin,andchylousascitesmayresultinafalselyhigh
SAAG
•Theaccuracyofthealbuminassayatlowalbuminconcentrations(e.g.,<1g/dL[10g/L])
shouldbeconfirmed(Ifserumalbumin<1.1g/dL/asciticcirrhosis,theSAAGwillbefalselylow)
•Serumhyperglobulinemia(serumglobulinlevel>5g/dL[50g/L])highasciticfluidglobulin
concentrationnarrowthealbumingradient(contributingtotheoncoticforces)
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Corrected SAAG = uncorrected SAAG x 0.16 x serum globulin (g/dL) + 2.5
SERUM-ASCITES ALBUMIN GRADIENT (SAAG)
(4)

37. ADA,adenosinedeaminase;AFB,acid-fastbacilli;Ascprot,ascitestotalproteinlevels;CT,computedtomography;CUS,cardiac
echosonography;HVPG,hepaticvenouspressuregradient;SAAG,serum–ascitesalbumingradient;TJLB,transjugularliverbiopsy
Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology,
Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors,
Wiley Blackwell, pp. 2087-2106

38. Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri,
J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106
Anstee Q. M., Jones D. E. J. (2014), Davidson's Principles and Practice of Medicines, Brian R. Walker,
et al., Editors, Churchill Livingstone, Elsevier, pp. 921-942

39. PROTEIN
•Determinesusceptibilityofdevelopingbacterialinfection
•Cirrhoticpatientswithanascitesprotein<1.0g/dL
1
or<1.5g/dL
2
haveahigherriskof
developinginfection(SBP)
•Ascitesdoesnotbecomean“exudate”withinfection(≠pleura)=asciticfluidtotalprotein
concentrationdoesnotincreaseduringSBP
1,3
•inperitonealprocesses(leakageofhighproteinmesentericlymphfromobstructedlymphatics
and/orfromaninflamedperitonealsurface)
•Exudativeascitesisalsopresentinascitessecondarytoheartfailure
highorlowtotalasciticproteinleveltocategorize
1.Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106
2.EASL (2010), J Hepatol, 53 (3), pp. 397-417
3.Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576

40. Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106

41. GLUCOSE
•Smallenoughtodiffusereadilyintobodyfluidcavitiesconcentrationofglucoseinascitic
fluid=inserum(unlessglucosebeingconsumedbyasciticfluidWBCsorbacteria)
•AsciticfluidglucoseinearlydetectedSBPissimilartothatofsterilefluid
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A., Hoefs J. C. (1985), Hepatology, 5 (2), pp. 257-9

42. LACTATE DEHYDROGENASE
•Toolargetoenterasciticfluidreadilyfrombloodusuallyislessthanhalfoftheserumlevel
inuncomplicatedascites/cirrhosis
•InSBP:LDHbecauseofthereleaseofLDHfromneutrophilsasciticfluidconcentration>
serum
•Secondaryperitonitis,theLDHleveliseven>inSBPandmaybeseveral-foldhigherthan
theserumLDHlevel
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Akriviadis E. A., Runyon B. A. (1990), Gastroenterology, 98 (1), pp. 127-33

43. SECONDARY PERITONITIS
•Measurementofasciticfluidtotalprotein,glucose,andLDHhasbeenreportedtobeofvalue
indistinguishingSBPfromsecondaryperitonitis(gutperforationintoascites)
•Neutrocyticasciticfluid+2/3followingcriteria=likelytohavesurgicalperitonitis:
1.totalprotein>1g/dL,
2.glucose<50mg/dL,
3.LDHabovetheupperlimitofnormalforserum(225U/L)
•Thesecriteriaand/orpolymicrobialinfection:96%sensitive/detectingsecondarybacterial
peritonitis
Akriviadis E. A., Runyon B. A. (1990), Gastroenterology, 98 (1), pp. 127-33
Soriano G., Castellote J., Alvarez C., et al. (2010), J Hepatol, 52 (1), pp. 39-44

44. Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark
Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-
1576

45. SMEARS AND CULTURE
•Mostcommonbacterialinfectionofasciticfluid:SBP(monomicrobial,withalowbacterial
concentrationmediancolonycountofonly1organism/mL)
•SBP:morelikebacteremia(numberofbacteriapresent)culturingasciticfluidasifitwere
bloodhasahighyieldsuperiorityofthebloodculturebottlemethod+bedsideinoculation
•Geneprobes:commerciallyavailableforthedetectionofbacteremia
•50%oftheculturesarestillnegative
•Simultaneousbloodculturesshouldbecollected(30%–58%ofSBPcasesareassociated
withbacteremia)
•Gramstain:positivein<athirdofthecasesofSBP
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3
Runyon B. A., Canawati H. N., Akriviadis E. A. (1988), Gastroenterology, 95 (5), pp. 1351-5
Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106

46. SMEAR AND CULTURE FOR TB
•Adirectsmearofasciticfluidtodetectmycobacteria:almostneverpositive(~3%)(rarityof
tuberculousperitonitis,lowconcentrationofmycobacteriainasciticfluidintuberculousperitonitis)
•Conventionalculturemedia:4–8weekstodetectAFB
•Cultures:determinesusceptibilitytoantimicrobialagents
•Mycobacteriumculture:50%sensitive
laparoscopywithhistologyandcultureofperitonealbiopsieshasasensitivityapproaching
100%
•DNAprobes
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Hillebrand D. J., Runyon B. A., Yasmineh W. G., et al. (1996), Hepatology, 24 (6), pp. 1408-12

47. ADENOSINE DEAMINASE
•Enzymerelatedtoproliferationanddifferentiationoflymphocytes
•AppearstobeafastanddiscriminatingtestfordiagnosisPTB
•RecommendedinsuspectedPTB,espendemicareas
•Cut-offvaluesfrom36to40IU/Lwithanoptimalcut-offpointof39IU/L
Garcia-Tsao G. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 2087-2106
Riquelme A., Calvo M., Salech F., et al. (2006), J Clin Gastroenterol, 40 (8), pp. 705-10

48. CYTOLOGY
•Only58–75%sensitiveindetecting“malignantascites”(whentumorcellslinetheperitoneal
cavity)
•Patientswithperitonealcarcinomatosishaveviablemalignantcellsexfoliatingintoasciticfluid
thesecellsdetectedintheirasciticfluidcytologies
•DNAcytometryimprovethesensitivityofeffusioncellanalysisto95%
Runyon B. A. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1553-1576
Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.

49. BILIRUBIN
•Thebilirubinconcentrationshouldbemeasuredinasciticfluidthatisdarkbrown
•Asciticfluidbilirubin>6mg/dL(102µmol/L)and>serumlevelsuggestsbiliaryorproximal
smallintestinalperforationintoasciticfluid
Runyon B. A. (1987), J Clin Gastroenterol, 9 (5), pp. 543-5
Akriviadis E. A., Runyon B. A. (1990), Gastroenterology, 98 (1), pp. 127-33

50. TRIGLYCERIDE
(1)
•Shouldbemeasuredinopalescentorfranklymilkyasciticfluid
•Accumulationofperitonealfluidrichintriglyceridespresenceoflymphintheabdominal
cavity
•Chylousascites=TG>200mg/dL(2.26mmol/L)and>serumlevel;usually,thelevelis
greaterthan1000mg/dL(11.30mmol/L)
Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.

51. •Pathogenesis
•Disruptionofthelymphaticsystem/obstruction(malignantinfltrationorinflammatory)
•Traumaticinjury(surgery,trauma)
•Alteredhemodynamicscaval(constrictivepericarditis)andhepaticvenouspressures
(cirrhosis)increasedformationofhepaticductlymph.
•SAAGmaybefalselyelevatedinchylousascites
•Lymphangiographyandlymphoscintigraphy
Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.
TRIGLYCERIDE
(2)

52. UNUSEFUL TESTS
•pH
•Lactate
•Fibronectin
•Cholesterol
•CEA
•α1-antitrypsin
•Cyclicadenosinemonophosphate
•(cAMP)
•Glycosaminoglycans
Runyon B. A. (2012), Schiff's Diseases of the Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley Blackwell, pp. 393-420.
Runyon B. A., AASLD (2013), Hepatology, 57 (4), pp. 1651-3

53. ABDOMINAL PARACENTESIS
PHUNG HUY HOANG, MD
Resident in Internal Medicine
Pham Ngoc Thach University of Medicine
June, 2017

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withchronicliverdisease",JLabClinMed,102(2),pp.260-73.
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