Approach to peritoneal fluid analysis

Dr Yasir M KhayyatAssistant Professor ,Consultant Gastroenterologist

Umm AlQura University

Pathophysiology of Cirrhotic Ascites

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History in Ascites • Onset,progression,severity (breathing),precipitating and

relieving factors• Associated :fever, abdominal

pain ,nausea,vomiting,jaundice• Liver disease history:viral,alcoholic,etc,or established

cirrhosis• Previous Investigations or treatment• Sacral, Scrotal and lower limbs edema• Rule out other abdominal distension causes: Intestinal

obstruction-Dilated bowel-Internal bleeding.• Identify PPT factors of Ascites: compliance,diet,other

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• Vital signs:fever,tachycardia,tachpnea• General: Encephalopathy,Jaundice,resp distress• JVP: distension due to RHF• CVS: • RESP: pleural effusion• ABDOMEN:Inspection: everted umbilicus, flank fullness,striaePalpation:Percussion: [ Flank dullness( if absent this means that there is < 10%

chance of having Ascites) there is at least 1.5 liters of Ascites if dullness is present], shifting dullness, fluid thrill.

• Lower Limbs: pitting edema

Physical Examination in Ascites

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Paracentesis Procedure

• Indication: new onset Ascites in inpatient or outpatient .

• Ascitic Tapping ( movie demonstration)• Prophylactic use of IV FFP or platelets is not

needed before paracentesis.• 15 gauge needle 3.25 inch is better than 14

gauge is more successful in obtaining paracentesis.

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Ascitic fluid analysis panel

• Cell count: differential ,PMN,% neutrophils on differential.

• Chemistry: Albumin, total protein,LDH,glucose,amylase

• SAAG : Serum Albumin- Ascites Albumin• Microbiology: gram stain, cultures ( aerobic and

anaerobic),TB stain ( AFB)• Cytology:senstivity of 3 samples is better 96.7%

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Interpretation of Ascitic fluid infection findingsAscitic fluids cultureAbsolute PMN /mm3

SBPPositive250≤Culture negative neutrocytic Ascites

No growth250≤

Monomicrobial non neutrocytic Ascites

Positive <250

Polymicrobial bacteriascitesPositive<250

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Underlying cause of Ascites: The DD

Remember at least 4 causes each8

Khayyat ,Approach to peritoneal fluid analysis

Treatment of Ascitic fluids Infection

5 days of IV antibiotics

5 days of IV

antibiotics

5 days of IV antibiotics

5 days of IV antibiotics +

anaerobic coverage

( metronidazole)

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Guidelines of Ascites treatment

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