Summary
Definition
History and exam
Key diagnostic factors
- abdominal pain or tenderness
- signs of ascites
- fever
- nausea/vomiting
- diarrhea
- altered mental status
- gastrointestinal bleed
Other diagnostic factors
- hypothermia
- hypotension
- tachycardia
Risk factors
- decompensated hepatic state (usually cirrhosis)
- low ascitic protein/complement
- gastrointestinal bleeding
- endoscopic sclerotherapy for esophageal varices
- ascites due to malignancy, renal insufficiency, or congestive heart failure
- extraintestinal infection
- invasive procedures
- use of proton-pump inhibitors (PPIs)
Diagnostic tests
1st tests to order
- CBC
- serum creatinine
- LFT
- prothrombin time/INR
- blood cultures
- ascitic fluid appearance
- ascitic fluid absolute neutrophil count (ANC)
- ascitic fluid culture
- ascitic fluid protein, glucose, lactate dehydrogenase (LDH), pH
Tests to consider
- serum-ascites albumin gradient (SAAG)
- ascitic fluid carcinoembryonic antigen (CEA)
- ascitic fluid alkaline phosphatase
- ascitic fluid AFB stain and culture, fungal culture, microscopy for ova/parasites
- ascitic fluid lactoferrin
- CT scan abdomen
Emerging tests
- highly-sensitive leukocyte esterase reagent strip testing of ascitic fluid (Periscreen)
- bedside (standard urine) leukocyte esterase reagent strip testing of ascitic fluid
Treatment algorithm
community-acquired infection with low risk for resistant species
nosocomial infection, septic shock, high risk for MDR organisms
Contributors
Authors
Brian Chinnock, MD
Associate Professor of Emergency Medicine
UCSF Fresno Medical Education Program
Fresno
CA
Disclosures
BC is an author of references cited in this topic.
Peer reviewers
Ke-Qin Hu, MD
Director, Hepatology Services, H.H. Chao Comprehensive Digestive Disease Center
Professor of Medicine
School of Medicine
University of California, Irvine
Irvine
CA
Disclosures
KQH declares that he has no competing interests.
Andrea De Gottardi, MD, PhD
Visiting Hepatologist
Hepatic Hemodynamic Laboratory
Liver Unit
Hospital Clinic
Barcelona
Spain
Disclosures
ADG declares that he has no competing interests.
References
Key articles
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Aug;74(2):1014-48.Full text Abstract
European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69(2):406-60.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Secondary peritonitis
- Tuberculous peritonitis
- Intraperitoneal hemorrhage into ascitic fluid
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- Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)
- Use of albumin infusion for cirrhosis-related complications: an international position statement
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