Ascites is an abnormal buildup of fluid in the abdomen. The most common cause is liver cirrhosis. Patients experience abdominal swelling and pressure. Ascites is diagnosed through physical exam, imaging, and lab tests. Lab tests help distinguish between transudative ascites caused by increased hydrostatic pressure, and exudative ascites caused by inflammation. The fluid-to-serum albumin gradient measured in lab tests indicates whether the cause is portal hypertension or another source.

1. ASCITES AND ASCITIC FLUID

2. INTRODUCTION
• Ascites is the abnormal build up of the fluid in
the abdomen
• The normal volume of peritoneal fluid is
around 100ml and it is clear and straw
coloured
• In the developed countries, the most common
cause is liver cirrhosis

3. SIGNS AND SYMPTOMS
• Mild ascites is hard to notice, but severe
ascites leads to abdominal distension
• Patients with ascites generally will complain of
progressive abdominal heaviness and pressure
as well as shortness of breath due to
mechanical impingement of the diaphragm

4. CONT….
• Ascites is detected on physical examination of the
abdomen by visible bulging of the flanks in the
reclining patient or fluid wave in case of massive
ascites
• Other signs of ascites may be present due to its
underlying cause for example in portal
hypertension, due to cirrhosis or fibrosis of the
liver patients may complain of leg swelling,
bruising, gynecomastia or mental changes due to
encephalopathy

5. CONT….
• Those with ascites due to heart failure may
complain about shortness of breath
• Those with ascites due to cancer (peritoneal
carcinomatosis may complain of chronic
fatigue or weight loss

6. CAUSES
• Cirrhosis – 81% (alcoholic in 65%, viral in 10%
cryptogenic in 6%)
• Heart failure – 3%
• Hepatic venous occlusion e.g. in Budd-chiari
syndrome or venous-occlusive disease
• Constrictive pericarditis

7. CONT….
• Kwashiorkor
• Cancer eg primary peritoneal carcinomatous
• Infection eg tuberculosis and spontaneous
bacteria peritonitis
• Pancreatitis
• Nephrotic syndrome etc

8. DIAGNOSIS
• The diagnosis of ascites requires a multiple
steps
Imaging studies
Lab studies
Laparoscopy

9. CONT….
• Basic metabolic panel
• Liver enzymes
• Serum –ascites albumin gradient (SAAG)

10. LAB STUDIES
Basic metabolic panel
• Serum and ascitic fluid protein and albumin
analysis
• Ascitic fluid glucose
• Lactate dehydrogenase
• Cholesterol

11. CONT….
Liver enzymes
• AST
• ALT
• GGT
• ALPS
• LDH

12. CONT….
Serum –ascites albumin gradient (SAAG)
SAAG = serum albumin – albumin level of ascitic
fluid
• SAAG is a better discriminant than older
measures (transudate versus exudate) for the
causes of ascites
• A high gradient (>1.1g/dl) indicates the ascites is
due to portal hypertension
• A low gradient (<1.1g/dl) indicates ascites of non
– portal hypertensive as a cause

13. TRANSUDATE AND EXUDATE
• Transudate is extravascular fluid with low protein
content and a low specific gravity (1.012)
• An exudate is any fluid that filters from the
circulatory system like lesions or areas of
inflammation
• It can be a pus – like or clear fluid
• When an injury occurs, leaving skin exposed, it
leaks out of the blood vessels and into nearby
tissues

14. CONT…
The fluid is composed of serum, fibrin, and
white blood cells
Exudate may ooze from cuts or from areas of
infection or inflammation

15. TRANSUDATE VS EXUDATE
• Caused mainly by increased hydrostatic pressure
and decreased in colloid osmotic pressure
• It clear by appearance
• Specific gravity -<1.012
• Protein content <2.5g/dl
• Fluid protein to serum protein <0.5
• SAAG - >1.2g/dl
• Fluid LDH <o.6
• Cholesterol <45mg/dl

16. EXUDATE
• Inflammation increased vascular permeability
• Cloudy in color
• Specific gravity >1.020
• Protein content >2.9g/dl
• Fluid protein/serum protein >0.5
• SAAG < 1.2g/dl
• Fluid LDH >0.6
• Cholesterol >45mg/dl