*Transudate (<30g/L protein) (Systemic disease) ◦ Liver (Cirrhosis) ◦ Cardiac e.g. RHF, CCF, SBE right heart valve disease and constrictive Pericarditis ◦ Renal failure ◦ Hypoalbuminaemia ( nephrotic syndrome or protein losing enteropathy *Exudate (>30g/L protein) (Local disease) ◦ Malignancy( mesothelioma or ovarian carcinoma) ◦ Venous obstruction e.g. Budd-Chiari, Schistosomiasis ◦ Pancreatitis ◦ Lymphatic obstruction ◦ Infection (especially TB) ◦ Esinophilic gastroenteriris or granulomatous peritonitis ◦ Peritoneal dialysis

Clear to pale yellow Normal Milk-coloured (Chylous) Malignant tumour, lymphoma, TB Parasitic infection, hepatic cirrhosis Cloudy/turbid Peritonitis, Primary bacterial infection Perforated bowel, appendicitis, pancreatitis Strangulated or infarcted bowel Bloody tap Benign or malignant tumour Haemorrhagic pancreatitis, perforated ulcer

LevelsInterpretation Triglyceride Elevated Malignant tumour, lymphoma, TB Parasitic infection, hepatic cirrhosis Protein g/dL >4g/dL Normal TB, SBP Glucose 7-10 <6 Normal TB and malignancy Amylase 50% of serum level Increased (Up to 5x serum level Normal Pancreatitis, pancreatic pseudocyst, pancreatic trauma or Intestinal strangulation Alkaline phosphatase Increased Small bowel perforation and strangulation

 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

 Serum albumin – Ascites albumin= SAAG (PORTAL HYPERTENSIVE) SAAG > 1.1 mg/dl ( NON PORTAL HYPERTENSIVE) SAAG < 1.1 mg/d 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 Peritoneal Carcinomatosis Tuberculous Peritonitis Pancreatic Ascites Bowel Obstruction Biliary Ascites Nephrotic Syndrome Posteroperative Lymphatic Leak Serositis in Connective Tissue Disease

Red cell countInterpretation None >100/microlitre >100,000/microlitre Normal Malignancy, TB Intra-abdominal trauma (DPL) White cell countInterpretation <300/microlitre >300/microlitre >25% neutrophils >25% lymphocytes Mesothelial cells Gram +ve cocci Gram –ve Normal Abnormal SBP (90%), cirrhosis (50%) TB or Chylous Ascites TB peritonitis Primary peritonitis Secondary peritonitis

 Total protein: In the past, ascitic fluid has been classified as an exudate if the protein level is greater than or equal to 2.5 g/dL. The total protein level may provide additional clues when used with the SAAG.  Culture/Gram stain: Culture has a 92% sensitivity for the detection of bacteria. In contrast, Gram stain is only 10% sensitive for visualizing bacteria.  Cytology: Cytology smears are reported to be 58-75% sensitive for detection of malignant ascites

 Serum proteins: 5g/L  Serum albumin: 3 g/l  Ascitic fluid protein 9 g/l  Ascitic fluid albumin:2.5 g/l  Glucose:5  DIAGNOSIS?