A gradient 97% accuracy and mandates a search for other causes such as peritoneal carcinomatosis, tuberculous peritonitis, pancreatitis, serositis, pyogenic peritonitis, and nephrotic syndrome (Table 44-1). Table 44-1 presents some of the disease states that produce high-SAAG and low-SAAG ascites. Although there is variability of the ascitic fluid in any given disease state, some features are sufficiently characteristic to suggest certain diagnostic possibilities. For example, blood-stained fluid with 25 g/L protein is unusual in uncomplicated cirrhosis but is consistent with tuberculous peritonitis or neoplasm. . | Chapter 044. Abdominal Swelling and Ascites Part 3 A gradient g dL low gradient suggests that the ascites is not due to portal hypertension with 97 accuracy and mandates a search for other causes such as peritoneal carcinomatosis tuberculous peritonitis pancreatitis serositis pyogenic peritonitis and nephrotic syndrome Table 44-1 . Table 44-1 presents some of the disease states that produce high-SAAG and low-SAAG ascites. Although there is variability of the ascitic fluid in any given disease state some features are sufficiently characteristic to suggest certain diagnostic possibilities. For example blood-stained fluid with 25 g L protein is unusual in uncomplicated cirrhosis but is consistent with tuberculous peritonitis or neoplasm. Cloudy fluid with a predominance of polymorphonuclear cells 250 pL and a positive Gram s stain are characteristic of bacterial peritonitis which requires antibiotic therapy if most cells are lymphocytes tuberculosis should be suspected. The complete examination of each fluid is most important for occasionally only one finding may be abnormal. For example if the fluid is a typical transudate but contains 250 white blood cells per microliter the finding should be recognized as atypical for cirrhosis and should warrant a search for tumor or infection. This is especially true in the evaluation of cirrhotic ascites where occult peritoneal infection may be present with only minor elevations in the white blood cell count of the peritoneal fluid 300-500 pL . Since Gram s stain of the fluid may be negative in a high proportion of such cases careful culture of the peritoneal fluid is mandatory. Bedside inoculation of blood culture flasks with ascitic fluid results in a dramatically increased incidence of positive cultures when bacterial infection is present 90 vs. 40 positivity with conventional cultures done by the laboratory . Direct visualization of the peritoneum laparoscopy may disclose peritoneal deposits of tumor tuberculosis or .
