Evaluation of Ascites

Causes of Ascites
Cause

Frequency

Cirrhosis

81%

Cancer

10%

Heart Failure

3%

Tuberculosis

2%

Dialysis

1%

Pancreatic Disease

1%

Other

2%

Source: UpToDate

Rare Causes of Ascites

Category
Infectious diseases

Amebiasis, Ascariasis,
Brucellosis, Chlamydia peritonitis,
Complications related to HIV
infection, Pelvic inflammatory
disease, Pseudomembranous
colitis, Salmonellosis, Whipple's
disease

Hematologic

Amyloidosis, Castleman's
syndrome, Extramedullary
hematopoiesis, Hemophagocytic
syndrome, Histiocytosis X,
Leukemia, Lymphoma,
Mastocytosis, Multiple myeloma

Miscellaneous

Abdominal pregnancy, Crohn's

disease, Endometriosis, Gaucher's
disease,
Lymphangioleiomyomatosis,
Myxedema, Nephrotic syndrome,

Imaging
Ultrasound with
Dopplers
Easily confirms ascites
May see nodularity of
cirrhosis
Evaluate patency of
vasculature
No radiation, contrast

CT / MRI
Evaluation for malignancy

Tests on Ascitic Fluid

Routine

Optional

Unusual

Cell count and

differential

Glucose
concentration

Tuberculosis smear
and culture,
adenosine deaminase

Albumin
concentration

LDH concentration

Cytology

Total protein
concentration

Gram stain

Triglyceride
concentration

Culture in blood
culture bottles

Amylase
concentration

Bilirubin
concentration

Cell Count, differential and

culture
Is ascites infected?
Greater than 250 PMN = SBP
If ascites is bloody ( > 50,000 RBC/mm3), correct
by subtracting 1 PMN / 250 RBC

Is ascites bloody?
5% of pts w/ cirrhosis - spontaneous or s/p
traumatic tap.
Non-traumatic associated with malignancy

20% of malignant ascites

10% of peritoneal carcinomatosis

Serum to Ascites Albumin

Gradient
Is portal hypertension present?
97% accurate
SAAG > 1.1 g/dL Portal HTN
SAAG < 1.1 g/dL Other causes

The serum-ascites albumin gradient is superior to the exudatetransudate concept in the differential diagnosis of ascites. Runyon BA;
Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann
Intern Med 1992 Aug 1;117(3):215-20.

Serum to Ascites Albumin

Gradient
SAAG > 1.1 g/dL

SAAG < 1.1 g/dL

Cirrhosis

Peritoneal carcinomatosis

Alcoholic hepatitis

Peritoneal tuberculosis

CHF

Pancreatitis

Massive hepatic metastases

Serositis

Budd Chiari Syndrome

Nephrotic syndrome

Congestive heart
failure/constrictive pericarditis

Total Protein
Exudate ( > 2.5 g/dL) or Transudate?
Supplanted by SAAG

Is there gut perforation? (vs SBP)

Total protein >1 g/dL
Glucose <50 mg/dL (2.8 mmol/L)
LDH greater than serum ULN

Glucose and LDH

Consistent with infection or malignancy?
Infection and cancer consume glucoselow

LDH is a larger molecule than glucose,

enters ascitic fluid with difficulty.
Ascitis/Serum LDH ratio
~ 0.4 in cirrhotic ascites
Approaches 1.0 in SBP
>1.0, usually infection or tumor

Other tests
Amylase
Uncomplicated cirrhotic ascites
About 40 IU/L. The AF/S ratio is about 0.4

Pancreatic ascites
About 2000 IU/L. The AF/S ratio is about 6

Triglycerides run on milky fluid.

Chylous ascites - TG > 200 mg/dL, usually
1000 mg/dL

Bilirubin run on brown ascites.

Biliary perforation AF Bili > serum Bili

Tests for TB
Smear extremely insensitive
Culture 62-83% when large volumes
cultured
Cell count mononuclear cell
predominance
Adenosine deaminase
Enzyme involved in lymphoid maturation
Falsely low in pts with both cirrhosis and TB

Cytology
almost 100% with peritoneal
carcinomatosis have positive cytology
Malignant ascites from massive
hepatic mets, HCC, lymphoma are
usually negative
Overall sensitivity for detection of
malignancy-related ascites is 58 to 75
%

Not helpful
Some tests of ascitic fluid appear to
be useless. These include pH,
lactate, and humoral tests of
malignancy such as fibronectin,
cholesterol, and many others

Biopsy
Cirrhosis

Fatty Liver

http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#2

Causes of Cirrhosis
Cause

Testing

Alcoholic liver disease

History, AST / ALT > 2

Chronic hepatitis C

Hep C Ab, Viral load

Primary biliary cirrhosis

Antimitochondrial antibodies

Primary sclerosing cholangitis

Contrast cholangiography , ANA,

Anti smooth muscle Ab, ANCA

Autoimmune hepatitis

Type 1: ANA, ANCA antismooth

muscle Ab Type 2: anti-LKM-1

Chronic hepatitis B

Hepatitis B serologies

Hemochromatosis

Ferritin, genetic testing

Wilsons disease

Ceruloplasmin

Alpha-1-antitrypsin deficiency

Serum AAT

Nonalcoholic fatty liver disease

Hx of DM or metabolic syndrome

Malignant Ascites
Definition: abnormal accumulation of fluid
in the peritoneal cavity as a consequence
of cancer.
Commonly caused by cancers of:
Breast, bronchus, ovary, stomach, pancreas,
colon

20% of cases have tumors of unknown

primary
Survival poor usually less than 3 months
Becker, G. Malignant ascites: Systematic review and guideline for treatment.
European Journal of Cancer 42 (2006) 589 - 597

Malignant Ascites:
Pathophysiology
Obstruction of lymphatics by tumor
Prevents absorption of fluid and protein

Alteration in vascular permeability

Hormonal mechanisms (VEGF, IL2, TNF
alpha)

Decreased circulating blood volume

Activates RAAS leading to Na retention
Becker, G. Malignant ascites: Systematic review and guideline for treatment.
European Journal of Cancer 42 (2006) 589 - 597

Pathophysiology of Malignant
Ascites

http://www.fresenius.de/internet/fag/com/faginpub.nsf/Content/Pressemapp

Management of Malignant
Ascites
Therapeutic paracentesis
Removing up to 5L appears safe
No good data on role of volume expanders

Diuretics
Equivocal evidence of efficacy
May be helpful for portal HTN
Less/minimally useful when no portal HTN

Drainage Catheters
Peritoneovenous shunts

Peritoneovenous Shunt
Contraindications
Protein > 4.5 g/l (occlusion)
Loculated ascites
Coagulopathy
Advanced renal/cardiac disease
GI malignancy

Complications

Denver Shunt
(Similar to LaVeen Shunt)

Infection
Hematogenous spread of mets
DIC
Pulmonary edema
Pulmonary emboli

Transjugular intrahepatic
portosystemic shunt (TIPS)

References
1.
2.

3.

4.
5.

Up to Date
Ascites and renal dysfunction in liver disease, Second edition. Edited by
Pere Gins, Vicente Arroyo, Juan Rods, and Robert W. Schrier. Malden,
Mass., Blackwell, 2005.
The serum-ascites albumin gradient is superior to the exudate-transudate
concept in the differential diagnosis of ascites. Runyon BA; Montano AA;
Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992
Aug 1;117(3):215-20.
Becker, G. Malignant ascites: Systematic review and guideline for
treatment. European Journal of Cancer 42 (2006) 589 - 597
Aslam, N. Malignant ascites; New concepts in pathophysiology, diagnosis,
and management. Arch Intern Med. Vol 161. Dec 10/24, 2001.