Question 14

College Answer

Ascitic fluid analysis provides – Fluid for General appearance

Albumin / protein content

Red cell count White cell count Culture and sensitivity Cytology

Biochemistry - amylase

Indications for performing a tap include: any patient with ascites and PUO, critical illness or suspected malignancy.

Discussion

I would expand the college list:

Information which can be derived from an ascitic fluid analysis:

• Appearance - turbidity would be very suspicious for SBP
• Albumin - to calculate serum/ascites albumin gradient
• Amylase/lipase - to consider pancreatitis as the cause of ascites
• LDH (low indicates hepatic cause, whereas >500 suggests malignancy)
• Gram stain - for bacteria
• India ink stain - for hyphae
• ZN stain for acid-fast bacilli (tuberculosis)
• Culture/sensitivities
• Flow cytometry and cell count - RBC/WCC ratio would raise suspicion of SBP
• Cytology - presence of malignant cells
• alpha-foetoprotein - to investigate for HCC

Indications for ascitic fluid drainage:

• Diagnostic
  • see above
• Therapeutic
  • patient discomfort
  • respiratory compromise due to adominal pressure
  • abdominal compartment syndrome
  • infected ascitic fluid (i.e. as source control)
  • for peritoneal dialysis (this can be viewed as a therapeutic paracentesis

Bar-Meir, Simon, Emanuel Lerner, and Harold O. Conn. "Analysis of ascitic fluid in cirrhosis." Digestive diseases and sciences 24.2 (1979): 136-144.

Boyer, Thomas D., Arthur M. Kahn, and Telfer B. Reynolds. "Diagnostic value of ascitic fluid lactic dehydrogenase, protein, and WBC levels." Archives of internal medicine 138.7 (1978): 1103-1105.

Runyon, Bruce A., John C. Hoefs, and Timothy R. Morgan. "Ascitic fluid analysis in malignancy‐related ascites." Hepatology 8.5 (1988): 1104-1109.