MEDizzy - A 61-year-old man is admitted to your service for swelling

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A 61-year-old man is admitted to your service for swelling of the abdomen. You detect ascites on clinical examination and perform a paracentesis. The results show a WBC count of 300 leukocytes/μL with 35% polymorphonuclear cells. The peritoneal albumin level is 1.2 g/dL, protein is 2.0 g/dL, and triglycerides are 320 mg/dL. Peritoneal cultures are pending. Serum albumin is 2.6 g/dL. Which of the following is the most likely diagnosis?

ExplanationDiagnostic paracentesis is part of the routine evaluation in a patient with ascites. Fluid should be examined for its gross appearance, protein content, cell count and diferential, and albumin. Cytologic and culture studies should be performed when one suspects infection or malignancy. The serum-ascites albumin gradient (SAG) offers the best correlation with portal pressure. A high gradient (>1.1 g/dL) is characteristic of uncomplicated cirrhotic ascites and differentiates ascites caused by portal hypertension from ascites not caused by portal hypertension in more than 95% of cases. Conditions that cause a low gradient include more “exudative” processes such as infection, malignancy, and inflammatory processes. Similarly, congestive heart failure and nephrotic syndrome cause high gradients. In this patient, the SAG is 1.5 g/dL, indicating a high gradient. The low number of leukocytes and polymorphonuclear cells makes bacterial or tubercular infection unlikely. Chylous ascites often is characterized by an opaque milky fuid with a triglyceride level greater than 1000 mg/dL in addition to a low SAG.