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Diagnostic paracentesis (50–100 mL) essential. Routine evaluation includes gross inspection, protein, albumin, glucose, cell count and differential, Gram’s and acid-fast stains, culture, cytology; in selected cases check amylase, LDH, triglycerides, culture for tuberculosis (TB). Rarely, laparoscopy or even exploratory laparotomy may be required. Ascites due to CHF (e.g., pericardial constriction) may require evaluation by right-sided heart catheterization.
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Differential Diagnosis
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Cirrhosis counts for 84% of cases of ascites. Cardiac ascites, peritoneal carcinomatosis, and “mixed” ascites resulting from cirrhosis and a second disease account for 10–15%.
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Diseases of peritoneum: Infections (bacterial, tuberculous, fungal, parasitic), neoplasms, connective tissue disease, miscellaneous (Whipple’s disease, familial Mediterranean fever, endometriosis, starch peritonitis, etc.).
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Diseases not involving peritoneum: Cirrhosis, CHF, Budd-Chiari syndrome, hepatic venoocclusive disease, hypoalbuminemia (nephrotic syndrome, protein-losing enteropathy, malnutrition), miscellaneous (myxedema, ovarian diseases, pancreatic disease, chylous ascites).
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Pathophysiologic Classification Using Serum-Ascites Albumin Gradient (SAAG)
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Difference in albumin concentrations between serum and ascites as a reflection of imbalances in hydrostatic pressures and can be used to differentiate between potential causes of ascites (Fig. 43-1).
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