1. Approach to peritoneal fluid analysis Dr Yasir M Khayyat Assistant Professor,Consultant Gastroenterologist Umm AlQura University

2. Pathophysiology of Cirrhotic Ascites Khayyat,Approach to peritoneal fluid analysis 2

3. History in Ascites Onset,progression,severity (breathing),precipitating and relieving factors Associated :fever, abdominal pain,nausea,vomiting,jaundice Liver disease history:viral,alcoholic,etc,or established cirrhosis Previous Investigations or treatment Sacral, Scrotal and lower limbs edema Rule out other abdominal distension causes: Intestinal obstruction-Dilated bowel-Internal bleeding. Identify PPT factors of Ascites: compliance,diet,other 3 Khayyat,Approach to peritoneal fluid analysis

4. Vital signs:fever,tachycardia,tachpnea General: Encephalopathy,Jaundice,resp distress JVP: distension due to RHF CVS: RESP: pleural effusion ABDOMEN: Inspection: everted umbilicus, flank fullness,striae Palpation: Percussion: [ Flank dullness( if absent this means that there is < 10% chance of having Ascites) there is at least 1.5 liters of Ascites if dullness is present], shifting dullness, fluid thrill. Lower Limbs: pitting edema Physical Examination in Ascites 4 Khayyat,Approach to peritoneal fluid analysis

5. Paracentesis Procedure Indication: new onset Ascites in inpatient or outpatient. Ascitic Tapping ( movie demonstration) Ascitic Tapping Prophylactic use of IV FFP or platelets is not needed before paracentesis. 15 gauge needle 3.25 inch is better than 14 gauge is more successful in obtaining paracentesis. 5 Khayyat,Approach to peritoneal fluid analysis

6. Ascitic fluid analysis panel Cell count: differential,PMN,% neutrophils on differential. Chemistry: Albumin, total protein,LDH,glucose,amylase SAAG : Serum Albumin- Ascites Albumin Microbiology: gram stain, cultures ( aerobic and anaerobic),TB stain ( AFB) Cytology:senstivity of 3 samples is better 96.7% 6 Khayyat,Approach to peritoneal fluid analysis

7. Interpretation of Ascitic fluid infection findings Absolute PMN /mm3Ascitic fluids culture 250≤ Positive SBP 250≤ No growth Culture negative neutrocytic Ascites < 250 Positive Monomicrobial non neutrocytic Ascites <250 Positive Polymicrobial bacteriascites 7 Khayyat,Approach to peritoneal fluid analysis

8. Underlying cause of Ascites: The DD High gradient Ascites >1.1 g/dl ( > 11g/l) Low gradient Ascites <1.1 g/dl ( <11g/l) Cardiac Ascites Budd Chiari syndrome Myexedma Cirrhosis postoperative lymphatic leakage Pancreatic, Biliary Ascites TB,Nephrotic syndrome, Remember at least 4 causes each 8 Khayyat,Approach to peritoneal fluid analysis

9. Treatment of Ascitic fluids Infection SBP Culture negative neutrocytic Ascites Monomicrobi al non neutrocytic Ascites Polymicrobial bacteriascites 5 days of IV antibiotics 5 days of IV antibiotics + anaerobic coverage ( metronidazole) 9 Khayyat,Approach to peritoneal fluid analysis

10. Furosemide : spironolactone 40:100 ratio Max: 160:400 If Gynecomastia  amiloride 10-40 mg po/day Salt restriction: < 2 g /day or 88 mmol/day If Na < 120-125 water restriction is needed. Dietary Drug incompliance For large volume Ascites Patients with complications secondary to portal hypertension Hospitalization Precipitati ng causes Diuretics Restriction Guidelines of Ascites treatment 10 Khayyat,Approach to peritoneal fluid analysis