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Approach to the differential diagnosis of ascites


Ascites refers to the accumulation of fluid in the peritoneal cavity, and its diagnosis and management require a systematic approach. Here's how you can approach it based on the flowchart:

  1. Abdominal Paracentesis: The first step in evaluating ascites is to perform an abdominal paracentesis to obtain ascitic fluid for analysis.

  2. Gross Appearance of Fluid:

  • Transparent Yellow: Suggestive of uncomplicated ascites.

  • Cloudy Yellow: May suggest infection and warrants further cell count analysis.

  • Bloody: Possible malignancy or trauma; subtract 1 white blood cell (WBC) for every 750 red blood cells (RBCs) to correct the WBC count.

  • Milky: Likely chylous ascites; triglyceride concentration is measured.

  • Dark Brown: Suggests bilirubin content; bilirubin concentration is measured.

  1. Special Testing:

  • Cell Count Correction: Corrects for bloody taps.

  • Triglyceride Concentration: Assesses chylous ascites.

  • Bilirubin Concentration: Differentiates between bile leakage or hepatic ascites.

  1. White Blood Cell Count (WBC):

  • <250 cells/mm³: Considered uncomplicated ascites or Nonneutrocytic Bacterascites (NNCA).

  • ≥250 cells/mm³: Suggests possible Spontaneous Bacterial Peritonitis (SBP) or Culture-Negative Neutrocytic Ascites (CNNA) and requires further analysis of polymorphonuclear leukocytes (PMNs).

  1. Polymorphonuclear (PMN) Count:

  • <50% PMNs: Further testing may be warranted based on clinical suspicion.

  • ≥50% PMNs: Suggestive of SBP; check total protein, glucose, and lactate dehydrogenase (LDH) levels.

  1. Serum-Ascites Albumin Gradient (SAAG):

  • ≥1.1 g/dL: Indicates that the ascites is likely due to portal hypertension. Conditions such as cirrhotic ascites, cardiac ascites, and Budd-Chiari syndrome fall into this category.

  • <1.1 g/dL: Points to ascites not caused by portal hypertension. Examples include nephrotic ascites, malignancy-related ascites, and pancreatic ascites.

  1. Total Protein:

  • <2.5 g/dL: Further categorizes the ascites into specific types like nephrotic or malignancy-related ascites.

  • ≥2.5 g/dL: Typically associated with cardiac ascites.

  1. Other Tests and Considerations:

  • For Uncomplicated Cirrhotic Ascites: Imaging such as ultrasound or liver biopsy may be necessary.

  • For Cardiac Ascites: A chest roentgenogram and echocardiogram are recommended.

  • For Nephrotic Ascites: A 24-hour urine protein excretion test can be diagnostic.

  • For SBP: A clinical response to antibiotics is confirmatory.

  1. Confirmatory Testing:

  • Secondary Bacterial Peritonitis: Requires additional imaging and investigations.

  • Pancreatic Ascites: Abdominal computed tomography (CT) is indicated.

  • Peritoneal Carcinomatosis: Ascitic fluid cytology, imaging, and search for primary malignancy.

  • Tuberculous Peritonitis: Mycobacterial culture and analysis of underlying causes.

  1. Differential Diagnosis:

  • Uncomplicated Cirrhotic Ascites:

  • Caused by cirrhosis, leading to portal hypertension.

  • Patients may present with a gradual increase in abdominal girth and weight gain.

  • Management includes sodium restriction, diuretics, and potentially therapeutic paracentesis.

  • Cardiac Ascites:

  • Results from chronic right-sided heart failure.

  • There is often accompanying peripheral edema and jugular venous distention.

  • Treatment targets the underlying cardiac condition, often with diuretics and management of heart failure.

  • Nephrotic Ascites:

  • Occurs with severe proteinuria due to nephrotic syndrome.

  • The ascites are often associated with marked hypoalbuminemia.

  • The primary approach includes managing the nephrotic syndrome with corticosteroids or other immunosuppressants and supportive care.

  • Spontaneous Bacterial Peritonitis (SBP):

  • An infection of the ascitic fluid without an apparent intra-abdominal source.

  • Typically presents with acute abdominal pain, fever, and altered mental status in patients with cirrhosis.

  • Treatment involves prompt antibiotic therapy and intravenous albumin.

  • Secondary Bacterial Peritonitis:

  • Caused by an intra-abdominal source of infection, such as a perforated viscus.

  • The ascitic fluid culture often grows multiple organisms.

  • Requires surgical intervention in addition to antibiotics.

  • Pancreatic Ascites:

  • Due to pancreatic disease, such as acute pancreatitis or pancreatic duct rupture.

  • The ascitic fluid typically has high amylase levels.

  • Treatment focuses on managing the underlying pancreatic pathology and nutritional support.

  • Peritoneal Carcinomatosis and Portal Hypertension:

  • Peritoneal carcinomatosis can cause ascites independent of portal hypertension, commonly associated with ovarian or gastrointestinal malignancies.

  • Treatment may involve chemotherapy, targeted therapy, or palliative care.

  • Tuberculous Peritonitis and Underlying Cirrhosis:

  • An uncommon cause of ascites, often associated with chronic liver disease.

  • The diagnosis is made with ascitic fluid analysis showing elevated protein and lymphocyte predominance and confirmed with mycobacterial cultures or biopsy.

  • Antituberculous therapy is the cornerstone of treatment.

  • Peritoneal Carcinomatosis Alone:

  • Malignant cells from primary tumors spread to the peritoneal surfaces, causing ascites.

  • Diagnosed with imaging and cytology of ascitic fluid.

  • Management might include systemic chemotherapy, intraperitoneal chemotherapy, or surgery.

  • Tuberculous Peritonitis Alone:

  • Infection of the peritoneum with Mycobacterium tuberculosis in the absence of cirrhosis.

  • Ascites fluid analysis shows elevated protein, predominantly lymphocytes and adenosine deaminase.

  • Treatment requires a prolonged course of antituberculous medications.

  • Infectious Ascites:

  • Spontaneous Bacterial Peritonitis (SBP):

  • Pathophysiology: SBP is typically a complication of cirrhosis with portal hypertension. It occurs due to bacterial translocation, where gut bacteria migrate to mesenteric lymph nodes and then into the bloodstream, resulting in bacteremia and infection of the ascitic fluid.

  • Diagnosis: A diagnosis of SBP is made when the ascitic fluid PMN count is ≥250 cells/mm³ with a positive culture. Clinical signs include fever, abdominal pain, and tenderness, along with potential tachycardia and signs of ascites like shifting dullness and fluid thrill.

  • Treatment: SBP is treated with antibiotics to cover typical causative organisms, such as gram-negative enteric bacteria. Cefotaxime at a dose of 2 grams IV every 8 hours for 5 days is standard. Albumin infusion may also be given to patients with renal impairment or those at risk of hepatorenal syndrome.

  • Culture-Negative Neutrocytic Ascites (CNNA):

  • Pathophysiology: Similar to SBP, CNNA is seen in the setting of cirrhosis and is presumed to be due to bacterial translocation. However, in CNNA, ascitic fluid culture is negative, which could be due to the low number of bacteria or prior antibiotic use.

  • Diagnosis: CNNA is diagnosed when a patient with clinical signs of SBP has an ascitic fluid PMN count of ≥250 cells/mm³, but no organisms are grown in culture.

  • Treatment: Treatment is generally the same as for SBP since the clinical presentation is indicative of an infection, even in the absence of a positive culture. Antibiotics are administered based on the assumption that bacteria are present but not detected.

  • Nonneutrocytic Bacterascites (NNCA):

  • Pathophysiology: NNCA occurs when bacteria are present in the ascitic fluid, likely due to transmural migration from the gut, but without an inflammatory response, as indicated by a PMN count less than 250 cells/mm³.

  • Diagnosis: The diagnosis is based on a positive bacterial culture from ascitic fluid in the absence of an elevated PMN count.

  • Treatment: The management of NNCA may not always involve antibiotics. The decision is based on the patient's clinical condition and the repeat ascitic fluid analysis. If there is no clinical evidence of infection and the PMN count remains low, antibiotics may be withheld, but close monitoring is essential.


In all these conditions, the approach to management must be tailored to the individual patient's clinical status and the results of ascitic fluid analysis. Supportive care for symptoms and prophylactic strategies to prevent recurrence play vital roles. Primary prophylaxis could include norfloxacin or similar antibiotics, particularly after a gastrointestinal bleed, while secondary prophylaxis is aimed at preventing recurrence in patients who have already had an episode of SBP.

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