A 47-year-old man comes to the office due to bloating and abdominal discomfort for the past 2 months. The patient's abdomen has become progressively enlarged in association with a 9-kg (19-lb) weight gain. He also notes fatigue and difficulty breathing while walking up and down steps but denies chest pain or palpitations. The patient drinks 8-10 beers a day but does not use tobacco or illicit drugs. He has no relevant medical history. Temperature is 37.5 C (99.5 F), blood pressure is 130/65 mm Hg, pulse is 75/min, and respirations are 15/min. Physical examination shows scleral icterus, palmar erythema, and multiple spider angiomas. The abdomen is distended and nontender, and a fluid wave is present. A right upper quadrant ultrasound demonstrates a nodular, shrunken liver as well as the presence of fluid in the intraperitoneal cavity. Diagnostic paracentesis reveals straw-yellow fluid. Which of the following fluid analysis tests should be performed?

Question

A 47-year-old man comes to the office due to bloating and abdominal discomfort for the past 2 months.  The patient's abdomen has become progressively enlarged in association with a 9-kg (19-lb) weight gain.  He also notes fatigue and difficulty breathing while walking up and down steps but denies chest pain or palpitations.  The patient drinks 8-10 beers a day but does not use tobacco or illicit drugs.  He has no relevant medical history.  Temperature is 37.5 C (99.5 F), blood pressure is 130/65 mm Hg, pulse is 75/min, and respirations are 15/min.  Physical examination shows scleral icterus, palmar erythema, and multiple spider angiomas.  The abdomen is distended and nontender, and a fluid wave is present.  A right upper quadrant ultrasound demonstrates a nodular, shrunken liver as well as the presence of fluid in the intraperitoneal cavity.  Diagnostic paracentesis reveals straw-yellow fluid.  Which of the following fluid analysis tests should be performed?

Quizplus · Accepted Answer

11ec25c8_d311_ab10_bc81_f37e37e80e63_MD0003_00 This patient with abdominal distension, weight gain, and a fluid wave has ascites. Although ascites can result from multiple disease processes, the most common etiology is cirrhosis, as suggested by this patient's shrunken, nodular liver on ultrasound, stigmata of chronic liver disease (ie, scleral icterus, palmar erythema, spider angiomas), and history of heavy alcohol use. multiple disease processes Evaluation of new-onset ascites includes diagnostic paracentesis for fluid analysis. Ascitic fluid color assessment, total protein count, and serum-ascites albumin gradient (SAAG; calculated by subtracting the peritoneal fluid albumin concentration from the serum albumin concentration) are performed to confirm the underlying etiology. Patients with cirrhosis typically have clear, yellow-tinged ascites with low protein (<2.5 g/dL) and a high SAAG (≥1.1 g/dL). Cell count and differential are also performed in all patients to rule out spontaneous bacterial peritonitis, a life-threatening infection of the ascitic fluid. Peritonitis symptoms usually include fever, abdominal pain, and mental status changes; however, findings may be subtle in early infection. The diagnosis is confirmed by an absolute polymorphonuclear cell count ≥250/mm³. Further testing is based on clinical presentation and is not required in patients with a presentation suggestive of ascites from cirrhosis. Further testing (Choice A) The ascites bilirubin level is elevated in the setting of a perforated biliary duct or bowel. Patients typically have brown (bilious) ascites, and present with sudden-onset, severe abdominal pain with peritoneal signs (eg, guarding). (Choice C) Cytology should be performed for patients in whom there is a concern for underlying malignancy-usually those with persistently bloody ascites and cachexia. Yellow ascitic fluid is more suggestive of benign ascites from cirrhosis. (Choice D) Fluid pH is obtained when assessing pleural fluid (ie, after a thoracentesis), and a low pH (<7.30) often indicates infection, malignancy, or rheumatoid effusion. pH does not have diagnostic value in a paracentesis. (Choices E and F) Glucose and lactate dehydrogenase levels are obtained in patients with signs or symptoms concerning for infection, malignancy, or bowel perforation. These tests are less specific for infection than cell count and differential and are not indicated for routine screening. They are usually reserved for patients in whom there is high clinical suspicion (eg, fever, weight loss, severe abdominal pain). Educational objective: All patients with new-onset ascites require diagnostic paracentesis. Ascitic fluid cell count and differential should be performed to rule out spontaneous bacterial peritonitis, whereas fluid color assessment and measurement of albumin and total protein are needed to determine the underlying etiology. References: Management of adult patients with ascites due to cirrhosis: an update. (http://www.ncbi.nlm.nih.gov/pubmed/19475696) Introduction to the revised American Association for the Study of Liver Diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. (http://www.ncbi.nlm.nih.gov/pubmed/23463403)

A 47-Year-Old Man Comes to the Office Due to Bloating