Ascitic fluid analysis

A simplified description of ascitic fluid analysis. Aim of the presentation is to give a very clear understanding about the analysis of ascities.
Presentation will help the medical residents diagnose the cause of fluid accumulation in abdomen and thus will guide to adopt the appropriate pathway to solve the issue.

1. Ascitic Fluid
What do you do
Muhammad Asim Rana
MBBS, MRCP, MRCPS, FCCP, EDIC, SF-CCM
Critical Care Medicine
King Saud Medical City

2. Ascites
•Diagnosis:
•established with a combination of a physical
examination & an imaging test (USG).
•Approx 1500 mL of fluid had to be present for
flank dullness to be detected
•lesser degrees of ascites can be missed.
•Ultrasonography can be helpful when the physical
examination is not definitive

3. Causes of Ascites
•Ascites can be classified based on the underlying
pathophysiology:
•Portal hypertension
–Cirrhosis
–Alcoholic hepatitis
–Acute liver
–Hepatic veno-occlusive disease (eg, Budd-Chiari syndrome)
–Heart failure
–Constrictive pericarditis
–Hemodialysis-associated ascites (nephrogenic ascites)

4. Causes of Ascites
•Hypoalbuminemia
–Nephroticsyndrome
–Protein-losing enteropathy
–Severe malnutrition
•Peritoneal disease
–Malignant ascites(eg, ovarian cancer, mesothelioma)
–Infectious peritonitis (eg, tuberculosis or fungal infection)
–Eosinophilicgastroenteritis
–Starch granulomatousperitonitis
–Peritoneal dialysis

5. Causes of Ascites
•Other etiologies
–Chylous ascites
–Pancreatic ascites (disrupted pancreatic duct)
–Myxedema
–Hemoperitoneum

7. International AscitesClub
Grading system
•Grade 1
–Mild ascitesdetectable only by ultrasound
examination
•Grade 2
–Moderate ascitesmanifested by moderate
symmetrical distension of the abdomen
•Grade 3
–Large or gross asciteswith marked abdominal
distension

8. Older system grades
•However, the validity of the grading system
has not yet been established. In particular, the
natural history of "grade 1" ascites is unclear.
Grades ascites from 1+ to 4+ is also used.
–1+ is minimal and barely detectable,
–2+ is moderate
–3+ is massive but not tense
–4+ is massive and tense

9. Abdominal Paracentesis
•Most efficient way to confirm the presence of
ascites, diagnose its cause, and determine if the
fluid is infected.
•Safe procedure, with an extremely low incidence of
serious complications despite the coagulopathythat is
usually present in patients with cirrhosis.
•Coagulation parameters beyond which
paracentesisshould be avoided.
•There are no data-supported however, patients with
clinically evident fibrinolysisor disseminated
intravascular coagulation should not undergo
paracentesis.

10. Tests performed on asciticfluid
•Routine tests
•Cell count and differential
•Albumin concentration
•Total protein concentration
•Culture in blood culture
bottles
•Optional tests
•Glucose concentration
•LDH concentration
•Gram stain
•Amylase concentration
•Other tests
•Tuberculosis smear and culture
•Cytology
•Triglyceride concentration
•Bilirubinconcentration

11. Asitic Fluid Appearance
Appearance interpretation
Clear Uncomplicated ascitesin the setting of cirrhosis is usually translucent
yellow
Turbid or cloudySpontaneously infected
Milky
"chylous
ascites"
Milky fluid usually has a triglyceride concentration greater than serum
and greater than 200 mg/dL(2.26 mmol/L) and often greater than 1000
mg/dL(11.3 mmol/L).
Cirrhosis ,abdominal malignancy& lymphatic abnormalities.
Pink or bloody
(RBC of
>10,000/mm3)
"traumatic tap“, or malignancy
Brown Deeply jaundiced patients have brown asciticfluid with a bilirubin
concentration approximately 40 percent of the serum value.
If the asciticfluid is as brown as molasses and the bilirubinconcentration
is greater than the serum value, the patient probably has a ruptured
gallbladder or perforated duodenal ulcer

12. Cell count and differential
•The cell count with differential is the single
most helpful test performed on ascitic fluid to
evaluate for infection.
•Polymorphonuclear count ≥ 250/mm3
–spontaneous bacterial peritonitis.
•In bloody ascites:
–one neutrophil should be subtracted from the
absolute neutrophil count for every 250 red cells
to yield the "corrected neutrophil count“.

13. Serum-to-Ascites Albumin gradient
•The serum-to-ascitesalbumin gradient (SAAG)
accurately identifies the presence of portal
hypertension and is more useful than the protein-
based exudate/transudateconcept.
•SAAG
–serum albumin value -asciticfluid albumin
–(obtained on the same day).
•SAAG ≥ 1.1 g/dL(11 g/L)
–Indicates portal hypertension
–(Budd-Chiarisyndrome, heart failure, or liver cirrhosis)
•SAAG <1.1 g/dL(<11 g/L)
–Indicates that the patient does not have portal hypertension.

14. Sending Cultures
•Bacterial cultures of asciticfluid should be sent
from patients with
–new onset ascites
•admitted with ascites
•Who deteriorate with
–Fever,
–Abdominal pain
–Azotemia,
–Acidosis
–confusion

15. Protein, Glucose, LDH
•Protein—Ascitic fluid had been classified as an exudate if the total
protein concentration is ≥2.5 or 3 g/dL and a transudate if it is
below this cut-off. However, the exudate/transudate system of
ascitic fluid classification has been replaced by the SAAG.
•Measurement of total protein, glucose, and lactate dehydrogenase
(LDH) in ascites may also be of value in distinguishing SBP from gut
perforation into ascites
•Patients with ascitic fluid that has a neutrophil count ≥250
cells/mm3 and meets two out of the following three criteria are
unlikely to have SBP and warrant immediate evaluation to
determine if gut perforation into ascites has occurred.
–Total protein>1 g/dL
–Glucose<50 mg/dL (2.8 mmol/L)
–LDHgreater than the upper limit of normal for serum.
–Bilirubin concentration should be measured in patients with brown ascites

16. Glucose, LDH, Amylase
Condition Glucose
Uncomplicated cirrhoticascitesSimilar to serum glucose
peritoneal carcinomatosis Low
gut perforation May be undetectable
Condition LDHasciticfluid/serum (AF/S) ratio
uncomplicated cirrhotic
ascites
0.4
SBP ratio approaches 1.0
infection or tumor. more than 1.0
Condition asciticAmylase AF/S ratio of amylase
uncomplicated cirrhotic
ascites
40 IU/L 0.4
pancreatitis or gut perforation ↑ ↑
Pancreaticascites ↑↑↑ (2000 IU/L)↑↑↑( 6.0)

17. Tests for tuberculous peritonitis
•Direct smear
•0 to 2% sensitivity in detecting Mycobacteria.
•Culture
•When one liter of fluid is cultured, sensitivity for Mycobacteria
62 to 83% .
•Fluid for PCR for tuberculosis .
•Cell count
•Tuberculousperitonitis can mimic the culture-negative variant
of SBP, but lymphocyte cells usually predominate in
tuberculosis.
•Adenosine deaminase
•Adenosine deaminaseactivity of asciticfluid has been proposed
as a useful non-culture method of detecting tuberculous
peritonitis; however, patients with cirrhosis and tuberculous
peritonitis usually have falsely low values .

18. Questions?
Thank you