Ascites: Differential Diagnosis based on Biochemistry - what radiologists should know

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Diagnostic Paracentesis: 


Biochemistry & microscopy: 

1. Albumin 

2. Total protein 

3. Cell count


SAAG: 

Serum ascites albumin gradient.

Serum albumin - ascites albumin

SAAG correlates with sinusoidal pressures. 

High SAAG correlates with portal hypertension (sinusoidal i.e cirrhosis or post sinusoidal i.e veno occlusive disease)


SAAG > 1.1: 

- Protein >2.5 = cardiac ascites, early budd chiari, sinusoidal obstruction syndrome (post sinusoidal disease) / mixed ascites

- Protein < 2.5 : cirrhosis / late budd chiari


SAAG < 1.1: malignancy / tuberculosis / pancreatic ascites / nephrotic syndrome / protein loosing enteropathy


CELL COUNT:

- PMN > 250 = High SAG = SBP

                     - Low SAAG = pancreatic ascites

- WBC > 500 + PMN <  250 = tuberculosis / malignancy


OTHER TESTS


1. Infection - Culture / glucose /LDH / gram stain / AF culture

2. Neoplasia: LDH / cytology

3. Chylous: Triglyceride

4. Bile leak: Bilirubin

5. Pancreatitis: Amylase


Prepared by Dr. Sharad Maheshwari

28.12.2022

Updated: 

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490258/

2. https://litfl.com/peritoneal-fluid-analysis/

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