Question 5.3

A 55-year-old patient is admitted with an exacerbation of chronic liver disease. Results of an ascitic tap and serum results are listed below:

ASCITIC FLUID
Parameter	Patient Value
Appearance	Clear Yellow
pH	micro-clots present, no value obtained
Red Cell Count	0 erythrocytes/µL
White Cell Count	378 leukocytes/µL
Ascitic Fluid Protein	25 g/L
Ascitic Fluid Albumin	18 g/L
Ascitic Fluid Lactic Acid Dehydrogenase (LOH)	480 U/L
Gram Stain	no organisms seen

SERUM
Parameter		Patient Value	Adult Normal Range
Serum	Protein	32 g/L*	60-80
Serum	Albumin	23 g/L*	35-50
Serum Lactic Acid Dehydrogenase (LOH)		320 U/L*	120- 250

a) List four possible underlying diagnoses. (20% marks)

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College answer

Spontaneous bacterial peritonitis

Perforated viscus

Cirrhosis

Malignancy

Discussion

Carrying on with theme for Question 5, this is another middle-aged gentleman with liver disease. This time, the question really is, "what does this ascitic tap mean". The history offered with the results ("exacerbation of liver disease"?) is so uninformative it may as well not exist.

So: using the 2009 article by Koulaouzidis and Such & Runyon (1998) as the main sources, one can concoct an unordered list which describes the reported findings, and their possible meaning.

Clear ascitic fluid: probably meaningless. About a third of such people could still have SBP (Aminiahidashti et al, 2014)
pH not available: that's a pity, because it could have been helpful - a pH < 7.3 seems to be strongly associated with SBP (Gitlin et al, 1982)
RBC of 0 cells per µL: a good sign, as haemorrhagic ascites (RBC count > 10,000) is prognostically terrible ( Urrunaga et al, 2013). The presence of micro-clots in the fluid suggests that the RBCs were there, but then clotted.
WCC in excess of 250 leukocytes/µL without any organisms potentially puts this in the territory of "culture-negative neutrocytic ascites". It meets the cell count criteria for SBP.
A high ascitic fluid protein and albumin suggest infection or malignancy. An albumin of 18 is too high for "plain" ascites of portal hypetension, as the SAAG (serum-ascites albumin gradient) is expected to be no higher than 11 g/L. So, the albumin should be no higher than 12 in this sample.
Ascitic LDH is elevated, also suggesting malignancy or infection. The LDH should be under 400 U/L, and the ascites:serum LDH ratio should be no higher than 0.6. In this scenario the ratio is (480/320) = 1.5.

So, in summary, what could this be?

Malignancy: there are lots of features
Bacterial SBP infection with a non-Gram-staining organism, eg. tuberculosis
Sarcoid-associated ascites
Pancreatitis-associated ascites
Abdominal fluid in the presence of bowel obstruction
It's not ascites! Could this have been urine?

References

Ward, Patrick CJ. "Interpretation of ascitic fluid data." Postgraduate medicine 71.2 (1982): 171-178.

Tarn, A. C., and R. Lapworth. "Biochemical analysis of ascitic (peritoneal) fluid: what should we measure?." Annals of Clinical Biochemistry 47.5 (2010): 397-407.

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.

Al-Mandeel, Hazem, and Abeer Qassem. "Urinary ascites secondary to delayed diagnosis of laparoscopic bladder injury." Journal of minimal access surgery 6.2 (2010): 50.

Develing, L., J. F. Hamming, and B. Speelberg. "[Chylous ascites following surgical repair of a ruptured abdominal aortic aneurysm]." Nederlands tijdschrift voor geneeskunde 147.31 (2003): 1513-1516.

Frank, Denis J., et al. "Traumatic rupture of the gallbladder with massive biliary ascites." JAMA 240.3 (1978): 252-253.

Cameron, JOHN L., et al. "Internal pancreatic fistulas: pancreatic ascites and pleural effusions." Annals of surgery 184.5 (1976): 587.

Berner, C., et al. "Diagnosis of ascites." British Medical Journal 282 (1981): 1499.

BERNER, CHARLES, et al. "Diagnostic probabilities in patients with conspicuous ascites." Archives of internal medicine 113.5 (1964): 687-690.

Aminiahidashti, Hamed, et al. "Diagnostic Accuracy of Ascites Fluid Gross Appearance in Detection of Spontaneous Bacterial Peritonitis." Emergency 2.3 (2014): 138.

Gitlin, Norman, John L. Stauffer, and Ronald C. Silvestri. "The pH of ascitic fluid in the diagnosis of spontaneous bacterial peritonitis in alcoholic cirrhosis." Hepatology 2.4 (1982): 408S-411S.

Urrunaga, Nathalie H., et al. "Hemorrhagic ascites. Clinical presentation and outcomes in patients with cirrhosis." Journal of hepatology 58.6 (2013): 1113-1118.

Pare, Pierre, Jean Talbot, and John C. Hoefs. "Serum-ascites albumin concentration gradient: a physiologic approach to the differential diagnosis of ascites." Gastroenterology 85.2 (1983): 240-244.

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.

Banerjee, Mithu, et al. "Biomarkers of malignant ascites—a myth or reality." Medical Journal Armed Forces India 67.2 (2011): 108-112.

Ekpe, E. E. L., and A. J. Omotoso. "The Relevance of Ascitic Lactate Dehydrogenase (LDH) and Serum Ascites Albumin Gradient (SAAG) in the Differential Diagnosis of Ascites among Patients in a Nigerian Hospital." Journal of Advances in Medicine and Medical Research (2015): 211-219.

Pattinson, H. A., et al. "Clotting and fibrinolytic activities in peritoneal fluid." BJOG: An International Journal of Obstetrics & Gynaecology 88.2 (1981): 160-166.

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