Question 28.5

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.


Patient Value

Adult Normal Range

Red Blood Cell

120 x 106/L*

< 5

White Cell Count

350 x 106/L*

< 300


50 x 106/L


300 x 106/L


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)


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College answer

Not available.


The abnormalities are:

  • Erythrocytosis
  • Lymphocytosis
  • Serum-ascites albumin gradient = (31 - 24) = 7 

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.