Chapter 044. Abdominal Swelling and Ascites (Part 3) pdf

Abdominal Swelling and Ascites Part 3 A gradient 97% accuracy and mandates a search for other causes such as peritoneal carcinomatosis, tuberculous peritonitis, pancreatitis, serositis

Chapter 044 Abdominal Swelling and Ascites

(Part 3)

A gradient <1.1 g/dL (low gradient) suggests that the ascites is not due to portal hypertension with >97% accuracy and mandates a search for other causes such as peritoneal carcinomatosis, tuberculous peritonitis, pancreatitis, serositis, pyogenic peritonitis, and nephrotic syndrome (Table 44-1) Table 44-1 presents some of the disease states that produce high-SAAG and low-SAAG ascites Although there is variability of the ascitic fluid in any given disease state, some features are sufficiently characteristic to suggest certain diagnostic possibilities For example, blood-stained fluid with >25 g/L protein is unusual in uncomplicated cirrhosis but is consistent with tuberculous peritonitis or neoplasm Cloudy fluid with a predominance of polymorphonuclear cells (>250/µL) and a positive Gram's stain are characteristic of bacterial peritonitis, which requires antibiotic therapy; if

most cells are lymphocytes, tuberculosis should be suspected The complete examination of each fluid is most important, for occasionally only one finding may be abnormal For example, if the fluid is a typical transudate but contains

>250 white blood cells per microliter, the finding should be recognized as atypical for cirrhosis and should warrant a search for tumor or infection This is especially true in the evaluation of cirrhotic ascites where occult peritoneal infection may be present with only minor elevations in the white blood cell count of the peritoneal fluid (300–500/µL) Since Gram's stain of the fluid may be negative in a high proportion of such cases, careful culture of the peritoneal fluid is mandatory Bedside inoculation of blood culture flasks with ascitic fluid results in a dramatically increased incidence of positive cultures when bacterial infection is present (90 vs 40% positivity with conventional cultures done by the laboratory) Direct visualization of the peritoneum (laparoscopy) may disclose peritoneal deposits of tumor, tuberculosis, or metastatic disease of the liver Biopsies are taken under direct vision, often adding to the diagnostic accuracy of the procedure

Table 44-1 Characteristics of Ascitic Fluid in Various Disease States

Cell Count Cond

ition

G ross Appeara

Pro tein, g/L

Se rum-Ascites Albumin

Re

d Blood

White Blood Cells,

Oth

er Tests

nce Gradient

, g/dL

Cells,

>10,000/µ

L

per µL

Cirrh

osis

St raw-colored

or bile-stained

<25 (95%)

>1 1

1% <250 (90%)a; predominantly mesothelial

Neopl

asm

St raw-colored, hemorrha gic, mucinous , or chylous

>25 (75%)

<1 1

20

%

>1000 (50%);

variable cell types

Cyt ology, cell block, peritoneal biopsy

Tuber

culous

Cl ear,

>25 <1 7% >1000

(70%);

Peri toneal

peritonitis turbid,

hemorrha gic, chylous

lymphocytes

biopsy, stain and culture for acid-fast bacilli

Pyoge

nic

peritonitis

Tu rbid or purulent

If purulent,

>25

<1 1

Un usual

Predom inantly

polymorphon uclear

leukocytes

Posi tive Gram's stain, culture

Cong

estive heart

failure

St raw-colored

Var iable, 15–

53

>1 1

10

%

<1000 (90%);

usually mesothelial, mononuclear

Nephr

osis

St raw-colored

<25 (100%)

<1 1

Un usual

<250;

mesothelial, mononuclear

If chylous, ether

or chylous

extraction, Sudan staining

Pancr

eatic ascites

(pancreatitis,

pseudocyst)

Tu rbid, hemorrha gic, or chylous

Var iable, often >25

<1 1

Var iable, may

be blood-stained

Variabl

e

Incr eased amylase in ascitic fluid and serum

a

Because the conditions of examining fluid and selecting patients were not identical in each series, the percentage figures (in parentheses) should be taken as

an indication of the order of magnitude rather than as the precise incidence of any abnormal finding