A 44-year-old man comes to the emergency department for exertional dyspnea, abdominal distention, and abdominal discomfort. He has a history of alcohol abuse, peptic ulcer disease, and acute pancreatitis. Physical examination shows a distended abdomen with shifting dullness and 1+ ankle edema. A diagnostic paracentesis is performed and shows the following: Blood studies show the following: Which of the following is the most likely cause of this patient's ascites?

Question

A 44-year-old man comes to the emergency department for exertional dyspnea, abdominal distention, and abdominal discomfort.  He has a history of alcohol abuse, peptic ulcer disease, and acute pancreatitis.  Physical examination shows a distended abdomen with shifting dullness and 1+ ankle edema.  A diagnostic paracentesis is performed and shows the following:  Blood studies show the following:  Which of the following is the most likely cause of this patient's ascites?

Quizplus · Accepted Answer

11ec25c8_d19f_f2aa_bc81_4793ae50d4bf_MD0003_00 Ascites can be due to portal hypertensive (eg, cardiac ascites, cirrhosis) or non-portal hypertensive (eg, malignancy, pancreatitis, nephrotic syndrome, tuberculosis) causes. Assessment of color, neutrophil count, total protein, and the serum-to-ascites albumin gradient (SAAG) in ascitic fluid analysis can help to diagnose the etiology. SAAG is calculated by subtracting the peritoneal fluid albumin concentration from the serum albumin concentration and is useful to differentiate between portal and non-portal hypertensive etiologies. A SAAG >1.1 g/dL indicates portal hypertension while a SAAG <1.1 g/dL suggests other causes. This patient's SAAG of 1.3 g/dL (3.8 - 2.5 g/dL) is consistent with portal hypertension (eg, cirrhosis) with increased hydrostatic pressure within hepatic capillary beds. > (Choice A) Decreased liver synthetic function leads to decreased serum albumin concentration and increased prothrombin time (INR). Hypoalbuminemia may contribute to edema in end-stage liver disease, but this patient's normal serum albumin makes this less likely. (Choice C) Increased capillary permeability (eg, malignant ascites) typically leads to non-portal hypertensive ascites with a SAAG <1.1 g/dL. (Choice D) Increased glomerular filtration pressure usually increases the glomerular filtration rate and decreases serum creatinine. However, it typically does not cause ascites. (Choice E) Although primary hyperaldosteronism causes sodium and water retention, it typically does not cause significant ascites or edema due to spontaneous diuresis (aldosterone escape phenomena). Educational objective: In evaluating ascites, a serum-to-ascites albumin gradient (SAAG) >1.1 g/dL indicates portal hypertensive etiologies (eg, cardiac ascites, cirrhosis) while a SAAG <1.1 suggests non-portal hypertensive etiologies (eg, malignancy, pancreatitis, nephrotic syndrome, tuberculosis). > References: Ascites: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/19577115) Serum-ascites albumin gradient in differential diagnosis of ascites. (http://www.ncbi.nlm.nih.gov/pubmed/24292307)

A 44-Year-Old Man Comes to the Emergency Department for Exertional