Lab Studies: Peritoneal fluid should be sent for cell count, albumin level, culture

Lab Studies:

• Peritoneal fluid should be sent for cell count, albumin level, culture, total protein, Gram stain, and cytology for new-onset ascites of unknown origin.

• Inspection: Most ascitic fluid is transparent and tinged yellow. A minimum of 10,000 red blood cells/?L is required for ascitic fluid to appear pink, and more than 20,000 red blood cells/?L is considered distinctly blood tinged. This may be attributed to either a traumatic tap or malignancy. Bloody fluid from a traumatic tap is heterogeneously bloody, and the fluid will clot. Nontraumatic bloody fluid is homogeneously red and does not clot because it has already clotted and lysed. Neutrophil counts of more than 50,000 cells/?L have a purulent cloudy consistency and indicate infection.

• Cell count: Normal ascitic fluid contains fewer than 500 leukocytes/?L and fewer than 250 polymorphonuclear leukocytes/?L. Any inflammatory condition can cause an elevated white blood cell count. A neutrophil count of more than 250 cells/?L is highly suggestive of bacterial peritonitis. In tuberculous peritonitis and peritoneal carcinomatosis, a predominance of lymphocytes usually occurs.

• SAAG: The SAAG is the best single test for classifying ascites into portal hypertensive (SAAG >1.1 g/dL) and non–portal hypertensive (SAAG <1.1 g/dL) causes. Calculated by subtracting the ascitic fluid albumin value from the serum albumin value, it correlates directly with portal pressure. The specimens should be obtained relatively simultaneously. The accuracy of the SAAG results is approximately 97% in classifying ascites. The terms high-albumin gradient and low-albumin gradient should replace the terms transudative and exudative in the description of ascites.

• Total protein: In the past, ascitic fluid has been classified as an exudate if the protein level is greater than or equal to 2.5 g/dL. However, the accuracy is only approximately 56% for detecting exudative causes. The total protein level may provide additional clues when used with the SAAG. An elevated SAAG and a high protein level are observed in most cases of ascites due to hepatic congestion. Those patients with malignant ascites have a low SAAG and a high protein level (see Causes).

• Culture/Gram stain: The sensitivity with bedside inoculation of blood culture bottles with ascites results in 92% detection of bacterial growth in neutrocytic ascites. Gram stain is only 10% sensitive for helping visualize bacteria in early-detected spontaneous bacterial peritonitis. Approximately 10,000 bacteria/mL are required for detection by Gram stain; the median concentration of bacteria in spontaneous bacterial peritonitis is 1 organism/mL.


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• Cytology: Cytology smear results are reported to be 58-75% sensitive for helping detect malignant ascites.

Ascites is generally treated simultaneously while an underlying etiology is sought (see above, diagnosis) in order to prevent complications (i.e., spontaneous bacterial peritonitis) and to prevent further progression. In patients with mild ascites, therapy can be done in the outpatient but should be gradual. If both ascites and peripheral edema is present, the goal of loss is no more than 1.0 kg/day and no more than 0.5 kg/day for those with ascites alone. In those with severe ascites, hospitalization is generally necessary.

Salt restriction is generally the baseline step in therapy, which allows diuresis since the patient now has more fluid than salt concentration. Since salt restriction is the basic concept in treatment, and aldosterone is one of the hormones that acts to increase salt retention, a medication that counteracts aldosterone should be sought. Spironolactone (or other distal-tubule diuretics such as triamterene or amiloride) is the drug of choice since they block the aldosterone receptor in the collecting tubule. Generally, the starting dose is spironolactone PO 100 mg/day (max 400 mg/day). A loop diuretic (furosemide, bumetanide, torasemide) may also be added to the regimen to further enhance diuresis and generally, furosemide (Lasix) is added at a dose of 40 mg/day (max 160 mg/day). Serum potassium level and renal function should be monitored closely while on these medications.

In those with severe ascites, therapeutic paracentesis may be needed in addition to medical treatments listed above. Ascites that is refractory to medical therapy is considered to be a classic indication for liver transplantation.

In a minority of the patient with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt (TIPS). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation.

Reclining minimizes the amount of salt the kidneys absorb, so treatment generally starts with bed rest and a low-salt diet. Urine-producing drugs (diuretics) may be prescribed if initial treatment is ineffective. The weight and urinary output of patients using diuretics must be carefully monitored for signs of

• hypovolemia (massive loss of blood or fluid)


• azotemia (abnormally high blood levels of nitrogen-bearing materials)


• potassium imbalance


• high sodium concentration. If the patient consumes more salt than the kidneys excrete, increased doses of diuretics should be prescribed

Moderate-to-severe accumulations of fluid are treated by draining large amounts of fluid (large-volume paracentesis) from the patient’s abdomen. This procedure is safer than diuretic therapy. It causes fewer complications and requires a shorter hospital stay.

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Large-volume paracentesis is also the preferred treatment for massive ascites. Diuretics are sometimes used to prevent new fluid accumulations, and the procedure may be repeated periodically.