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Peritoneal Fluid Analysis Peritoneal fluid (ascitic fluid) analysis The peritoneum is a tough semi-permeable membrane lining abdominal

l and visceral cavities. it encloses, supports and lubricates organs within the cavity. Paracentesis is effectively the analysis of Ascites the abnormal accumulation of fluid within the abdomen. The peritoneum is important in osmoregulation Passive diffusion of water and solute (up to a certain size) Maintains osmotic and chemical equilibrium with blood and lymph Ascitesdevelops either from: Increased accumulation Increased capillary permeability Increased venous pressure Decreased protein (oncotic pressure) Decreased clearance Increased lymphatic obstruction Cause Transudate (<30g/L protein) (Systemic disease) Liver (Cirrhosis) Cardiac e.g. RHF, CCF, SBE right heart valve disease and constrictive Pericarditis Renal failure Hypoalbuminaemia (nephrosis) Exudate (>30g/L protein) (Local disease) Malignancy Venous obstruction e.g. BuddChiari, Schistosomiasis Pancreatitis Lymphatic obstruction Infection (especially TB) Analysate Interpretation Gross appearance Clear to pale yellow Milk-coloured (Chylous) Normal Malignant tumour, lymphoma, TB Alkaline phosphatase Amylase Glucose Protein Triglyceride

Parasitic infection, hepatic cirrhosis Peritonitis, Primary bacterial infection Perforated bowel, appendicitis, pancreatitis Strangulated or infarcted bowel Benign or malignant tumour Haemorrhagic pancreatitis, perforated ulcer

Cloudy/turbid

o o o o o o o o o o o o o

Bloody tap

Paracentesis biochemistry Levels Elevated Interpretation Malignant tumour, lymphoma, TB Parasitic infection, hepatic cirrhosis Normal TB, SBP Normal TB and malignancy Normal Pancreatitis, pancreatic pseudocyst, pancreatic trauma or Intestinal strangulation Small bowel perforation and strangulation

0.3-4.0g/dL >4g/dL 7-10 <6

50% of serum level Increased (Up to 5x serum level

Increased

o o o

Exudate Serum:Ascites Ratios Evidence for these ascites:serum ratios is controversial Ascitic fluid protein/Serum Protein >0.5 Ascitic Fluid LDH/Serum LDH >0.6 Ascitic Fluid LDH >400 Presence of any 2 of these three findings is usually associated with TB, Malignancy or Pancreatitis Absence of all three usually indicates hepatic cause The Serum-Ascites Albumin Gradient (SAAG) The SAAG has become more favored in helping to characterize ascites fluid The concept surrounds oncotic-hydrostatic balance Simple calculation: Serum albumin Ascites albumin= SAAG SAAG > 1.1 mg/dl SAAG < 1.1 mg/d Peritoneal Carcinomatosis Tuberculous Peritonitis Pancreatic Ascites Bowel Obstruction Biliary Ascites Nephrotic Syndrome Posteroperative Lymphatic Leak Serositis in Connective Tissue Disease

>100/microlitre >100,000/microlitre

Malignancy, TB Intra-abdominal trauma (DPL) Interpretation

White cell count o o o <300/microlitre >300/microlitre >25% neutrophils >25% lymphocytes Mesothelial cells Gram +ve cocci Gram ve o o o

Normal Abnormal SBP (90%), cirrhosis (50%) TB or Chylous Ascites TB peritonitis Primary peritonitis Secondary peritonitis

Cirrhosis Alcoholic Hepatitis Cardiac Ascites Mixed Ascites Massive Liver Metastasis

Fulminant Hepatic Failure Budd-Chiari Syndrome Portal Vein Thrombosis Veno-Occlusive Disease Myxedema Fatty Liver of Pregnancy

Microscopy And Analysis Red cell count None Interpretation Normal