New onset ascites

Question: A 50 year old male with a longstanding history of alcohol abuse is seen by you for recent onset of ascites.  He has evidence of shifting dullness on exam along with significan pedal edema. Which of the following test results might cast doubt on your presumed diagnosis of alcohol-induced portal hypertension?

A. splenomegaly on abdominal ultrasound

B. a low serum albumin level

C. a low ascites albumin level

D. a high ascites total protein level

Answer:  Basic ascitic fluid analysis is critical in evaluation of the liver patient.  We are all taught about the serum-ascites albumin gradient (SAAG), that when > 1.1 is suggestive of portal hypertension.  Even with a low serum albumin level or a low ascites albumin level, you can still get a gradient > 1.1 and this would not necessarily cast any doubt on the diagnosis of Etoh cirrhosis. 

Bear in mind that cardiogenic causes also lead to a high SAAG, and it is the ascitic total protein that will make you think about the heart (when it’s > 2.5).  That makes answer choice D the correct answer.  Most alcoholics do not develop cirrhosis, just like most smokers do not develop emphysema.  This is why it is critically important to analyze new-onset ascites.

Splenomegaly on ultrasound is a common finding in cirrhosis.  If the patient above also had splenomegaly, it would lend further evidence toward the diagnosis of alcohol related cirrhosis and portal hypertension.

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