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Original Research Article Ascitic Fluid Analysis with Special Reference to Serum Ascites Cholesterol Gradient and Serum Ascites Albumin Gradient

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Original Research Article Ascitic Fluid Analysis with Special Reference to Serum Ascites Cholesterol Gradient and Serum Ascites Albumin Gradient International Journal of Research in Medical Sciences Sastry AS et al. Int J Res Med Sci. 2017 Feb;5(2):429-436 www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012 DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20170059 Original Research Article Ascitic fluid analysis with special reference to serum ascites cholesterol gradient and serum ascites albumin gradient Anand Sankar Sastry*, Subash Ch. Mahapatra, Vidyasagar Dumpula Department of General Medicine, Maharaja Institute of Medical College, Nellimarla, Vizianagaram, Andhra Pradesh, India Received: 02 January 2017 Revised: 03 January 2017 Accepted: 06 January 2017 *Correspondence: Dr. Anand Sankar Sastry, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Ascites being a common clinical problem with a vast spectrum of etiologies, less expensive and widely available biochemical parameters are required to differentiate ascites which can correlate with pathogenesis and pin point towards an etiology with high sensitivity and significant accuracy. Aims of the study were to determine the sensitivity, specificity and diagnostic efficacy of serum ascites albumin Gradient (SAAG) and that of ascitic fluid total protein (AFTP), evaluating their diagnostic role in identifying the etiology of ascites, to determine the diagnostic efficacy of Ascitic fluid cholesterol and serum ascites cholesterol gradient (SACG) in diagnosis of malignant ascites. Methods: In this study, 100 patients of ascitis were evaluated for ascitic fluid total protein, albumin, cholesterol, SAAG and SACG along with ultrasound and other required investigations. Results: Sensitivity, Specificity, and Diagnostic accuracy of SAAG for Portal hypertension were 97%, 85%, 96% respectively, whereas those of AFTP for exudative/transudative ascitis were 78.5%, 66%, 68% respectively. Ascitic fluid cholesterol and Mean SACG were significantly elevated in malignant ascites when compared with Non- Malignant Ascitis with p=0.0001. Similarly with a cut off level of 70mg% and 54 mg%, Ascitic fluid cholesterol and Mean SACG are having diagnostic accuracy of 90% and 93% respectively. Conclusions: SAAG is much more superior to AFTP in differential diagnosis of Ascitis. Ascitic fluid cholesterol and Mean SACG are simple and cost effective methods to separate malignant ascitis from non-malignant causes even in small centres with limited diagnostic facilities. Keywords: Malignant ascitis, Portal hypertension, Serum ascites cholesterol gradient, Serum ascites albumin gradient INTRODUCTION second disease.1 Pathophsiologically, Ascitis may be due to Portal Hypertension (Ex-Cirrhosis) or causes due to Ascitis defined as accumulation of free fluid in the pathology of peritoneum, which are not related to portal peritoneal cavity is a commonly encounterd clinical hypertension (Ex-Tubercular Peritonitis, peritoneal condition having varied etiologies and pathogenesis. carcinomatosis). Previous classification of Exudative and Analysis of Ascitic fluid is the easiest and most useful Transudative Ascitis based on AFTP is unable to way to pin-point the cause. Etiologically, Cirrhosis is the correctly identify the aetiological factors and offers little most common (84%), others being Cardiac ascites, insight to the pathophysiology of ascitic fluid infection (tuberculosis), peritoneal carcinomatosis, formation.2,3 It has been challenged in clinical conditions pancreatitis, and renal disease (nephrotic syndrome). especially in cirrhotic patients on prolonged diuretic Many causes are mixed resulting from cirrhosis and a theray, cardiac ascites, malignant ascites, and Mixed International Journal of Research in Medical Sciences | February 2017 | Vol 5 | Issue 2 Page 429 Sastry AS et al. Int J Res Med Sci. 2017 Feb;5(2):429-436 ascitis like cirrhotic patients with spontaneous bacterial and diagnostic accuracy of ascitic fluid cholesterol level peritonitis.4-7 and SACG in diagnosing malignant ascitis. Hence – SAAG [Serum Ascites Albumin Gradient] has METHODS been developed as a new approach, to classify ascites into two categories – High SAAG ascites with SAAG ≥1.1 This Prospective observational study on “ascitic fluid g/dl in cases with portal hypertension and Low SAAG analysis with special reference to SAAG and SACG” has ascites with SAAG <1.1 g/dl in cases with ascites, been carried out in in Department of Medicine, MIMS, unrelated to portal hypertension. SAAG reflects the Vizianagaram, a tertiary teaching hospital in North oncotic pressure exerted by Serum Albumin over Ascitic Andhra Pradesh during 2013 to 2016. The study was fluid Albumin which truly equals the high hydrostatic approved by Intuitional ethical committee and an pressure gradient between the portal bed and the ascitic informed written consent was obtained from patient. fluid. Inclusion criteria Therefore the difference between the serum and the ascitic fluid albumin concentrations correlates directly Patients with ascites proved by ultra sound with portal pressure. SAAG classification is much more Patients aged more than 18 years. physiologic and correlates well with the pathogenesis Patients with normal coagulation profile. even in patients on diuretic, cardiac ascitis and mixed ascitis. Various studies have shown superiority of SAAG Exclusion criteria in classifying ascites compared to transudate-exudate concept.8-10 The present study has been undertaken to Patients with blunt injury abdomen, compare sensitivity and diagnostic accuracy between Patients with coagulopathy or disseminated SAAG and AFTP in the differential diagnosis of ascites. intravascular coagulation (DIC). Now Ascitis due to Malignancies are on rise and difficult All patients with ascites were subjected to detailed to diagnose by routine Ascitic fluid analysis. Althouh history and thorough clinical examination, a base line SAAG accurately differentiate Ascitis due to Portal investigation - CBP, Urine Analysis, LFT, RFT, Serum Hypertension from other causes, but SAAG is not able to Cholesterol, Serum Albumin, ECG, CXR and ultrasound differentiate between malignant ascites and tuberculous scan of abdomen were performed. ascites as both are having low SAAG (<1.1 gm%).11 Diagnostic paracentesis was done with prior written Fluid cytology has low sensitivity for malignancy as the consent using 20-22 gauge 2.5 inch disposable needles differentiation between reactive atypical mesothelial cells 12,13 under sterile precautions using Z tract Technique. Around and malignant cells is sometimes difficult. Most of 50 ml fluid was aspirated and fluid was immediately sent the time, diagnosis in not possible without invasive and for Biochemical Analysis for Albumin, Total Protein, expensive investigations like CT abdomen, Biopsy and Cholestrerol, Glucose, Amylase, LDH, and ADA, FNAC of peritoneal nodes and diagnostic Cytological Analysis for Cell counts and Differential laparotomy/laparoscopy. So there is a need for more count, and Microbiological Analysis for gram stain, ZN specific and a highly sensitive new marker in stain and bacterial culture. presumptive diagnosis of ascites. Serum and Ascitic fluid Albumin were estimated in There are few studies regarding ascitic fluid cholesterol autoanalyser by Bromocresol green. Total Protein were level and SACG (serum ascites cholesterol gradient) as a estimated in autoanalyser by Biuret methods. The serum sensitive, cheap and non-invasive parameter in 13-17 cholesterol and Ascitic fluid cholesterol were also diagnosing malignancy related ascites. According to estimated. Serum samples for Cholesterol and Albumin Rana et al, Total Ascitic protein (70%), Ascitic serum were also sent at same time as Ascitic fluid sample for protein ratio (74%), ascitic leukocyte count (54%), and accurate calculation of SAAG and SACG. SAAG and malignant cytology (82%) yielded much lower diagnostic SACG were calculated simply subtracting the ascitic efficiency than ascitic fluid cholesterol (94%) in the fluid value from the serum value. diagnosis of malignant ascites.13 Special investigations like CT scan abdomen and Pelvis. Again a study by Sapna Vyakaranam et al shows Echocardiogram, Thyroid Profile, Upper GI endoscopy, cholesterol has been found to clearly differentiate 17 and FNAC of the peritoneal nodules and liver biopsy between tuberculous and malignant ascites. The were done in selected cases. elevated cholesterol levels in malignancy is due to the increased vascular permeability, increased cholesterol Diagnosis of liver cirrhosis conformed by clinical synthesis and release from malignant cells implanted on features of Portal HTN and Hepato-cellular failure, 13,18 peritoneum. As studies on this are very less, hence the alcoholic history, and ultra sound (Coarse hepatic present study has been undertaken to evaluate sensitivity echotexture with nodularity, Dilated collaterals International Journal of Research in Medical Sciences | February 2017 | Vol 5 | Issue 2 Page 430 Sastry AS et al. Int J Res Med Sci. 2017 Feb;5(2):429-436 around the gastroesophageal junction and splenic (44%) females with a sex ratio of 1.27. Majority of the hilum, Splenomegaly and dilated portal vein >14 mm cases i.e. 90 (90%) are aged above 30 years, and the total in diameter and splenic vein >12 mm).
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