A 76-year-old patient living in a shelter presents with weight loss and lethargy. On clinical examination, there is moderate ascites. A diagnostic ascites tap was performed with the result below.
|
Parameter |
Patient Value |
Adult Normal Range |
|
Red Blood Cell |
120 x 106/L* |
< 5 |
|
White Cell Count |
350 x 106/L* |
< 300 |
|
Neutrophils |
50 x 106/L |
|
|
Lymphocytes |
300 x 106/L |
|
|
Albumin |
24 g/L* |
35 – 50 |
|
Serum albumin |
31 g/L |
35 – 50 |
|
Slight milky coloured appearance |
||
a) Outline the abnormalities in the ascitic fluid and outline your rationale for the most likely diagnosis. (20% marks)
Not available.
The abnormalities are:
From that gradient, you can establish that portal hypertension is probably not the cause of this ascites (anything over 11g/L identifies portal hypertension as the cause of ascites). The milky appearance and the predominance of lymphocytes make malignancy more likely -most probably, a lymphoma. Tuberculosis is a valid alternative explanation, considering the domestic situation of the patient in the stem. Lastly, lymphatic obstruction and chylous ascites can be raised as a possibility, because the fluid would also be milky and full of lymphocytes.
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.
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.
Banerjee, Mithu, et al. "Biomarkers of malignant ascites—a myth or reality." Medical Journal Armed Forces India 67.2 (2011): 108-112.