MRCP PACES MANUAL

Investigations
A diagnostic tap is the key investigation, requesting the following
• The serum-ascites albumin gradient (SAAG): this is calculated by
subtracting the ascitic fluid albumin level from the plasma value. Values
>1.1 g/dL indicate portal hypertensive ascites. Values <1.1 g/dL indicate
non-portal hypertensive causes (most often infection or malignancy). This
has almost 100% accuracy in discriminating between these two
aetiological categories.
• Cell count: lymphocytic infiltrate is suggestive of tuberculous or
carcinomatous peritoneal disease, whereas neutrophils suggest bacterial
peritonitis.
• Culture/Gram stain and stain for acid-fast bacilli (AFBs).
• Cytology: if an adequate sample is taken for centrifugation
(approximately 500 mL), cytology has up to 75% sensitivity in detecting
malignant cells.
Other useful investigations include
• Echocardiography: if congestive cardiac failure is suspected
• Abdominopelvic CT: if malignancy is suspected
• Tumour markers
• Breast exam ± mammography
• Diagnostic laparoscopy.

Ultrasonography is useful for tapping small-volume or loculated ascites.

Management
The management of ascites in congestive cardiac failure is similar to that of
chronic liver disease (see above) with salt restriction and diuretics (eg
spironolactone).