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Introduction: Cirrhosis of the liver is a major health problem in our country. Patients with cirrhosis are at risk of developing esophageal varices and variceal bleeding with high mortality. They must undergo routine upper gastrointestinal endoscopy to screen for the presence of varices. This poses an economic, social, and medical burden. Thus, this warrants a non-invasive predictor of esophageal varices in a cirrhotic patient. The aim of this study was to find the correlation between SAAG and esophageal varices in portal hypertension due to cirrhosis of liver. Methods: Patients (45 males and 35 females) above 18 years of age and with cirrhosis of the liver underwent cross sectional observational study at Nepal Medical College Teaching hospital between October 2015 and December 2017 AD. Serum albumin and ascitic fluid albumin were analyzed on the same day and serum-ascites albumin gradient (SAAG) was calculated. Upper GI endoscopy was done to evaluate for the presence of esophageal and gastric varices. Pearson's chi-square test was applied to see the relation between SAAG and esophageal varices. Results: Among the 80 patients studied, 56.2% were male and 93.75% had varices. Majority of the patients who had esophageal varices had SAAG of more than 1.1 g/dL. A positive correlation was found between serum-ascites-albumin gradient and esophageal varices but was statistically not significant. A cut-off of >1.6 for SAAG to discriminate between presence and absence of varices yielded a sensitivity of 78.66% and a positive predictive value of 92.18%. Conclusion: This study highlighted that SAAG has a positive correlation with esophageal varices with high sensitivity and positive predictive value in estimating the presence of varices but without statistical significance. It has a low specificity. Due to statistically insignificant correlation and low specificity, SAAG cannot be used in place of upper GI endoscopy in diagnosing gastroesophageal varices

Background and aim: Majority of cirrhotic patients develop varices, the rate of variceal bleeding is 10-30% yearly with ‎death rate from bleeding is 17-57%. esophagogastroduodenoscopy (EGD) is an invasive and ‎unpleasant technique carrying rare but serious complications. We aimed to investigate the serum ‎ascites albumin gradient (SAAG) and portal vein congestion index (PCI) as non-invasive methods ‎for prediction of esophageal varices (EV) in patients with liver cirrhosis‎. Patients and Methods: ‎‎125 cirrhotic patients with ascites and no past history of EGD were included. Patients were ‎grouped into; Group I: 38 cirrhotic patients without EV. Group II: 87 cirrhotic patients with EV. ‎Patients were subjected to full clinical evaluation, calculation of SAAG, abdominal ultrasound ‎with a duplex study and measurement of PCI, and Esophagogastroduodenoscopy for detection and ‎grading of esophageal varices‎ ‎.‎ Results: Cirrhotic patients with EV had higher SAAG values (1.85 ‎‏±‏‎ 0.24 gm/dl) than cirrhotic patients ‎without EV (1.27 ‎‏±‏‎ 0.15 gm/dl). Additionally, cirrhotic patients with EV showed a higher PCI ‎than those without (0.16 ± 0.02 and 0.12 ± 0.01 respectively). For prediction of EV in cirrhotic ‎patients, SAAG had AUC 0.986 (p 1.4 with sensitivity 97.70% and ‎specificity 89.47% and portal congestion index, AUC was 0.974 (p 0.135 had ‎sensitivity 90.80% and specificity 94.74%‎‎‎. Conclusion: SAAG could be used as a non-invasive predictor for the presence of EV in cirrhotic patients along ‎with SAAG cutoff >1.4 requiring clinical attention. Combination of SAAG and PCI had a high ‎ability to predict esophageal varices in cirrhotic patients with AUC 1.000‎‎‎‎‎.

Background: Ascites and esophageal varices (EV) are the most common complications of portal hypertension, with an incidence of approximately 50%. Since effective preventive modalities have been established for variceal hemorrhage, early detection of EV is critical for primary prevention of bleeding. Serum-ascites albumin gradient (SAAG) can be considered an indirect parameter for the detection of EV and is useful in regions where there is a shortage of human and material resources to perform upper gastrointestinal endoscopy (UGE). The aim was to evaluate the role of serum-ascites albumin gradient (SAAG) in the prediction of esophageal varices (EV) in cirrhotic patients with ascites. Methods: All cirrhotic patients with ascites, identified by ultrasonography, who underwent measurement of SAAG, were included in this study. All patients underwent upper gastrointestinal endoscopy (UGE) for assessment of the presence and size of EV. Results: The study included 80 cirrhotic patients with ascites. The main causes of cirrhosis were alcohol intake (37.5%), hepatitis B virus (25.0%), and hepatitis C virus (15.0%). Patients with SAAG values &gt, 1.75 g/dL demonstrated EV with a sensitivity and specificity of 78.4% and 83.3%, respectively. SAAG values &gt, 1.8 g/dL were associated with the risk of large EV with AUC of 0.856, sensitivity of 88.24%, and specificity of 50.79%. The correlation coefficient (r) between SAAG and EV was 0.429, which was statistically significant (p &lt, 0.001). Conclusions: Cirrhotic patients with SAAG values ≥ 1.8 have a higher risk of large EV. In particular, those with values &gt, 1.9 who have higher possibility of bleeding must undergo upper GI endoscopy.

Background and Aims Placing a lumen-apposing metal stent (LAMS) through ascites carries serious risks, including death from leakage around the LAMS and failure to create a mature fistula between the 2 lumens. However, sometimes no options exist or are equally dangerous. We present 5 patients who underwent LAMS placement despite ascites in 2 different locations. Methods This is a retrospective review of 5 patients who underwent LAMS placement despite ascites in 2 different locations from 2016 to 2018. Results Three patients with cholecystitis and 2 patients with afferent limb syndrome and severe ascites were treated with a combination of preprocedural and intraprocedural paracentesis. Serum ascites albumin gradient was measured. Weight was recorded daily. Patients were encouraged to sleep at an incline, and periodic paracentesis (every 3-7 days) was performed when ascites reaccumulated over 4 weeks. Median volume of ascites aspirated was 2 L preprocedurally and 300 mL intraprocedurally. Only 1 patient had ascites with a high serum ascites albumin gradient and was treated with diuretics. Technical and clinical success was achieved in all 5 patients without any adverse events over a median follow-up of 28 weeks. Conclusions In situations in which no better options remain, LAMS placement appears to be safe after adequate and aggressive treatment of the underlying ascites pre-, intra-, and postprocedurally. Larger studies are needed to establish the safety of this approach.

Introduction: Ascites is the accumulation of fluid within the peritoneal cavity. Normally, 5-20ml of peritoneal fluid is found between the layers of peritoneum, acting as a lubricant and reducing the friction of organ movement during digestion and bodily movements. The use of serum ascites albumin gradient has out dated the total protein measurement in differentiating transudate from exudate fluid. Analysis is done in two broad spectrums: (1) Biochemical analysis (2) Clinical pathology and Cytological analysis Aim & Objectives: This study was done with the objective to evaluate the ascitic fluid analysis for differentiating transudate versus exudate and also the characteristics of the peritoneal fluid in various causes of ascites. Materials and Methods: In this study, 100 patients of ascites were evaluated for ascitic fluid total protein (AFTP) and Serum Albumin Ascitic Gradient (SAAG) along with ultrasound and other required investigations. Ascitic fluid was obtained by Paracentesis, an invasive sampling procedure to remove fluid or air from the peritoneal cavity for diagnostic or therapeutic purposes. The fluid obtained is sent for analysis. Ascitic fluid analysis is a group of tests used to diagnose the etiology of fluid accumulation. Result: Study shows that ascites due to various aetiology is common among 31-50 years of age group with a slight male predominance. The present study suggests that transudative ascites are more common than exudative ascites with a percentage of 52%. Conclusion: Serum Albumin Ascitic Gradient (SAAG) is much more superior to ascitic fluid total protein (AFTP) in the differential diagnosis of Ascites. Ascitic fluid analysis helps in diagnosing the aetiology of ascites based on the cytological and biochemical parameters. The common aetiology for ascites reported in India is liver cirrhosis. The development of ascites in cirrhotic patients is associated with a mortality of 15% and 44% at one-year and five-year follow-up periods, respecti

Nephrogenic ascites is described as a clinical condition of refractory ascites in patients with end-stage renal disease (ESRD) on renal replacement therapy. This entity was first described in 1970. Many nephrologists do not believe in nephrogenic ascites. The underlying etiologies can be multifactorial including a combination of poor nutrition, inadequate dialysis and ultrafiltration, increased peritoneal membrane permeability, and overall uremia. The nephrogenic ascites is a rare syndrome and is often associated with a grave prognosis especially if it is not diagnosed early and treated. In the present study, we report a 27-year-old woman with past medical history of diabetes type 1 (diagnosed at age 11), ESRD secondary to diabetic nephropathy on hemodialysis (diagnosis in December 2017), bilateral diabetic retinopathy, ovarian cyst, hypertension, and anxiety who presented to the emergency department for evaluation of intractable abdominal pain, nausea and vomiting for 2-day duration. She was found to have large ascites. Diagnostic paracentesis was done and found to be exudative with serum ascites albumin gradient (SAAG) of 0.7. After detailed workup, hepatic, cardiac, infectious and malignant causes for ascites were ruled out. The diagnosis of ascites of nephrogenic origin was made. Given the patient’s situation and her inability of self-care, she is not a good candidate for intra-abdominal dialysis. The patient has been treated conservatively with salt/fluid restriction and intensive hemodialysis with ultrafiltration. J Med Cases. 2020;11(1):26-29 doi: https://doi.org/10.14740/jmc3413

Introduction: As cites, a common entity in practice of gastroenterology is path physiologically divided into high SAAG and low SAAG category, to rapidly classify, formulate a workup plan and expedite the diagnosis. The cause of low SAAG as cites is often due to local peritoneal cause e.g. peritoneal tuberculosis, peritoneal carcinomatosis etc, mandating the need of peritoneoscopy for definitive diagnosis. This study aims to present the peritoneoscopy and peritoneal biopsy result of patients with low SAAG as cites of uncertain etiology. Methods: Peritoneoscopy was prospectively performed in 12 patients with low SAAG as cites of unclear etiology. Patients with low SAAG as cites and willing to give consent for peritoneoscopy were enrolled in the study. Patients underwent laparoscopic peritoneoscopy under general anesthesia and appropriate biopsies were taken during the procedure for histopathological analysis. Results: Of the twelve patients with low SAAG enrolled in the study, 3 (25%) were male and 75% (9) were female. The success rate of the procedure was 100% and there was no procedure related complications. Specific findings were seen in all patients undergoing peritoneoscopy. Of the twelve patients, 9 (75%) patients has metastatic deposits in the peritoneum, 3 (25%) had benign etiology, 2/3rd (2) of whom had granulomatous deposits suggestive of tuberculosis and 1/3rd (1) had extensive dense adhesions and peritoneal fibrosis. Primary focus was revealed (ovary) in only 1 patient undergoing peritoneoscopy. Conclusion: Peritoneoscopy with simultaneous biopsy is safe, efficient and accurate diagnostic method due to its high diagnostic capacity and low complication rate in selected patients who have low SAAG as cites of uncertain etiology.

Ascites is a condition of abnormal fluid accumulation in the peritoneal cavity that can be caused by many underlying diseases. Some studies conclude that ascitic fluid evaluation with transudate-exudate concept has been replaced by greater indicator, known as Serum Ascites Albumin Gradient (SAAG). This study aims to analyze the compatibility of SAAG and ascitic fluid evaluation to the clinical diagnosis of patients in Dr. Wahidin Sudirohusodo Hospital Makassar. The retrospective cross-sectional study was conducted by taking data from all patients with ascites condition examining both ascitic fluid and serum albumin simultaneously or within 3 days at the Dr. Wahidin Sudirohusodo Hospital Makassar from January – August 2018. The statistical analysis was performed for frequency distribution and Kappa statistical test to assess the compatibility of SAAG and ascitic fluid evaluation to clinical diagnosis of the patient. The study was conducted on 68 subjects and found that both ascitic fluid examination and SAAG were significantly compatible to the clinical diagnosis, 25.8% (p

Background: Globally Helicobacter Pylori (H. Pylori) infection and liver diseases are renowned with their high incidence rate. Recent studies have observed the relation between H. Pylori infection and liver disease progression to cirrhosis. This study aimed to determine the prevalence of H. pylori in liver cirrhotic patients. Patient and Methods: This study was conducted on 100 liver cirrhotic patients to detect H. Pylori infection based on UreA gene detection in ascites using nested polymerase chain reaction (nPCR). Biochemical analysis was performed on ascitic fluid, serum, complete blood count (CBC), and polymorph nuclear leukocytes count (PMN). Result: H. Pylori infection was detected in 75% of patients with liver cirrhosis. In ascitic fluid, H. pylori infection showed a highly significant association with albumin and PMN (P=0.0001) and also with other biochemical analyses including serum ascites albumin gradient (SAAG), specific gravity, and glucose (P=0.005, 0.0031, and 0.02, respectively). In serum only, the infection showed significant association with alkaline phosphatase, albumin, and hemoglobin with P values of 0.008, 0.014, and 0.008, respectively. Conclusion: The current study results shed light on the significant role of H. Pylori infection in ascites of patients with decompensated end-stage liver cirrhosis suggesting a prospective relation between H. pylori infection and liver diseases progression due to hepatic infections especially HCV.

Malignant mesothelioma is a rare neoplasm of the serosal linings. Mesothelioma has been linked to asbestos exposure, with prior asbestos exposure linked to 33-50% of malignant peritoneal mesotheliomas. We describe a case of malignant peritoneal mesothelioma (MPM) without any prior exposure to asbestos in a 40-year-old Hispanic female who presented to the emergency department with worsening abdominal pain and distension. She had a history of beta thalassemia trait and iron deficiency anemia. Examination revealed a distended abdomen with protruding umbilicus and positive shifting dullness. Laboratory tests showed anemia. Computed tomography (CT) of the abdomen revealed massive complex ascites suspicious of a malignant process. Ascitic fluid analysis showed serum ascites albumin gradient (SAAG) of 1.1 g/dL with a total protein of 5.2 g/dL. She underwent laparoscopic peritoneal biopsy which yielded epithelioid type malignant mesothelioma. She was started on chemotherapy with cisplatin and pemetrexed. The last follow-up was 27 months after the diagnosis. MPM is a rare and life-threatening malignancy. Frequently, the symptoms are non-specific. This poses a diagnostic challenge for physicians and probably the reason why the diagnosis is often delayed, especially in the absence of risk factors.

Hepatocellular carcinoma (HCC) affects more than half a million people worldwide each year. Paraneoplastic syndromes associated with HCC include erythrocytosis, hypercalcemia, hypercholesterolemia, hypoglycemia and thrombocytosis. Thrombocytosis is a rare paraneoplastic syndrome in HCC mediated by thrombopoietin (TPO) production. We report a case of thrombocytosis as a paraneoplastic syndrome in a patient with HCC and hepatitis C cirrhosis. A 56-year-old patient was evaluated with abdominal distension and pain of 1-month duration. He had a history of hepatitis C infection with liver cirrhosis, CTP (Child-Turcotte-Pugh) class C, MELD (model for end-stage liver disease) score 22, methadone dependence, alcohol abuse and depression. His physical examination was remarkable for distended abdomen with shifting dullness, palpable hepatomegaly and scleral icterus. Routine laboratory tests showed a platelet count of 754 k/µL, white blood cell count 12.4 k/µL, serum sodium level 128 mEq/L, alanine aminotransferase 93 U/L, aspartate aminotransferase 871 U/L, total serum bilirubin 4.3 mg/dL, direct serum bilirubin 2.8mg/dL and albumin 2.6 g/dL. Computed tomography of the abdomen and pelvis revealed hepatomegaly with numerous hypodensities suspicious for HCC. Abdominal paracentesis was done, serum ascites albumin gradient (SAAG) was 2.4 g/dL consistent with portal hypertension, and spontaneous bacterial peritonitis was ruled out. Magnetic resonance imaging of the liver was consistent with infiltrating HCC, portal vein thrombosis and retroperitoneal lymphadenopathy. His alpha fetoprotein (AFP) level was 79,102 ng/mL and TPO level was 126 pg/mL. JAK2 mutation was negative and no other cause of reactive thrombocytosis could be identified. One year prior to this admission, the patient was noted to have a normal platelet count and AFP level. He was not considered a candidate for liver transplantation due to ongoing substance abuse, and expired 1 month later. Thrombocytosis is a rare paraneoplastic condition seen in HCC. It is presumed to be secondary to increased production of TPO by the tumor. We observed an elevated level of TPO in our patient. Thrombocytosis in HCC is associated with a high tumor burden, portal vein thrombosis (PVT), serum AFP levels and a poor prognosis. Thrombocytosis in a cirrhotic patient should alert the presence of HCC and is associated with poor outcomes.

Background Paracentesis for management of ascites is frequently performed in hospices. Serum-ascites albumin gradient (SAAG) should be measured to guide management. Patients with ascites caused by portal hypertension have a SAAG 11 g/L. Usual management is to: • give human albumin solution (HAS) for renal-protective effects • prescribe spironolactone to reduce re-accumulation of ascites This practice is established in the management of portal hypertension due to cirrhosis. However, the incidence of portal hypertension in patients requiring paracentesis for malignant ascites is unknown. Methods In 2019 guidelines were written to ensure SAAG was checked for patients admitted to the hospice for paracentesis. These guidelines were audited in 2020. The audit covered an 11-month period, looking at whether SAAG was available pre-procedure, and whether HAS and spironolactone were given. Results 25 drains were inserted in 12 different patients. 100% of these patients had SAAG calculated. 67% (n=8) received HAS. 50% of this group (n=4) had a diagnosis of cirrhosis, and 50% (n=4) had metastatic malignancy. 3 of the patients given HAS were already on spironolactone, 3 were started on it post procedure (these were patients with malignant ascites), and 1 had their dose increased. 4 patients with malignant ascites received HAS and 3 were started on spironolactone. Conclusions Measuring SAAG demonstrated cases of malignant ascites associated with portal hypertension. This led to a change in management with increased use of HAS and spironolactone in patients with malignant ascites. All patients undergoing abdominal paracentesis should have SAAG recorded and used to determine appropriate use of HAS and spironolactone.

Peritoneal tuberculosis is a rare disease with increasing incidence in recent years, especially in patients with an immunocompromised state and liver cirrhosis. We report the case of a 37-year-old male with a known history of liver cirrhosis who presented to the hospital with abdominal pain, abdominal distension, and was diagnosed with peritoneal tuberculosis. The diagnosis was made based on findings from a CT of the abdomen and histopathological findings of peritoneal tissue biopsy. He was started on ethambutol, isoniazid, pyrazinamide, and rifampin for six months.

Eosinophilic ascites is a manifestation of serosal eosinophilic gastrointestinal disease. We present a 44-year-old male with low serum ascites albumin gradient with high eosinophil count and contrast-enhanced computed tomography of the abdomen showing circumferential wall thickening of the esophagus, mid to distal ileal loops, and ascending colon. The patient was managed with tablet prednisolone 20 mg twice daily for two weeks, then gradual tapering over one month. The patient responded to treatment. Awareness of the condition, timely diagnosis, and early treatment carries excellent responses.

Background and Aim Analysis of ascitic fluid is necessary to determine the etiology and to distinguish portal hypertension (PH)‐related and unrelated ascites. Numerous diagnostic parameters have been studied, but no single parameter has completely distinguished these. We aimed to validate the serum albumin–ascites gradient (SAAG) for the diagnosis of ascites secondary to PH and to establish cutoff points to predict PH using its sensitivity and specificity. Methods This was a cross‐sectional study conducted on patients diagnosed with ascites of any etiology. The SAAG and albumin concentration in ascitic fluid (AFA) were measured to establish their sensitivity and specificity for determining the presence or absence of PH. Cutoff points and levels of statistical significance were established based on the area under the curve. Results Eighty‐seven patients were evaluated, of whom 74 (84%) were men, with an average age of 54.0 ± 13.6 years. Seventy‐two (83%) were diagnosed at admission with PH‐related ascites and 15 (17%) with non‐PH‐related ascites. SAAG correctly classified 48 (67%) patients, but 24 (33%) were classified incorrectly, while AFA classified 59 (82%) correctly and only 13 (17%) incorrectly. The diagnostic accuracy of SAAG was 57 versus 73% for AFA. AFA had a sensitivity of 82% and specificity of 66% (95% confidence interval [CI]: 0.63–0.93), while SAAG had a sensitivity of 66% but a specificity of 86% (95% CI: 0.72–0.95). Conclusions The SAAG showed poor diagnostic performance with low sensitivity but high specificity. The diagnostic accuracy of AFA is superior to that of SAAG in discriminating between PH and non‐PH ascites., The serum albumin–ascites gradient (SAAG) and albumin concentration in ascitic fluid (AFA) were measured to establish their sensitivity and specificity for determining the presence or absence of portal hypertension (PH). The SAAG showed poor diagnostic performance with low sensitivity but high specificity. The diagnostic accuracy of AFA is superior to that of SAAG in discriminating between PH and non‐PH ascites.

Accumulation of free fluid in the peritoneal cavity is called ascites. The first step in identifying its etiology is to determine the serum-ascites albumin gradient (SAAG). According to this parameter, a high SAAG is regarded as a gradient greater than 1.1 g/dL. This condition has some differential diagnoses such as liver cirrhosis, Budd-Chiari syndrome, heart failure, and idiopathic portal fibrosis. In the present article, we present a young man with abdominal distention due to a high SAAG. Further evaluation of the abdominal and thoracic cavity revealed a mass in the posterior mediastinum, which had compressed the inferior vena cava and left atrium and led to Budd-Chiari syndrome. Evaluation of the biopsy sample showed fibrosarcoma. Mediastinal fibrosarcomas, though rare, should be considered in the differential diagnosis of mediastinal masses.

Background & aims The rate of mortality from Spontaneous Peritonitis (SP) in cirrhotic patients is still high despite the development of new antibiotic treatments and intensive hospital care. The coexistence of spontaneous fungal peritonitis (SFP) is almost entirely ignored health problem, because it is difficult to be diagnosed at an early stage by conventional culture-based methods. Therefore, this study was designed to employ PCR-based method in evaluating the prevalence of fungal infection in cirrhotic patients with peritonitis who failed to respond to the recommended therapy and to determine its association with in-hospital mortality. Subjects and Methods A total of 80 cirrhotic patients admitted to the hospital with ascitis (June-2013 to April-2015) were followed in this study. Results During hospitalization, 23 (42%) of patients had died although they received guideline-driven treatment. The demographics, clinical, hematological, and biochemical data were similar in both mortality and survival groups. However, the incidence of fungus infection was the only significantly elevated parameter in the mortality group than in the survival group (7/23;30% vs.0/32;0%, P = 0.0012). This fungal infection was significantly associated with SP drug resistance development (P = 0.007). Intriguingly, all the cases of fungal infection were detected by PCR-based method while culture-based diagnosis was able to detect the fungal infection in only 4 of these cases indicating a diagnostic sensitivity of 57%. Conclusion Our results reflect a strong association between SFP and in-hospital mortality in cirrhotic patients with SP that may offer a coherent explanation for the antibiotic treatment failure in such patients. Prompt PCR-detection and antifungal coverage is warranted in these cases.

Background: Serum-Ascitic Albumin Gradient (SAAG) can identify ascites related to portal hypertension. Esophageal varix (EV) is another feature of portal hypertension in cirrhosis. This study was done to find out the relation between SAAG and esophageal varices.Materials and methods: It was a cross- sectional descriptive study of 50 cases of cirrhotic ascites. SAAG was measured and upper gastrointestinal endoscopy was done for esophageal varices.Results: Among 50 cases, mean SAAG value 1.77 (±0.45 SD). Esophageal varices were found in 43(86%) cases. All cases with SAAG value >2.0gm/dl had EV. A significant statistical association was found between level of SAAG and the presence of esophageal varices (p=0.01).Conclusion: In patients of cirrhosis, the level of SAAG has positive association with the esophageal varices. This finding may permit us to use SAAG as a preliminary parameter of esophageal varices (EV) especially where endoscopy facilities are not available.TAJ 2014; 27(2): 36-38

Jenis cairan asites transudat atau eksudat perlu dibedakan sebagai tahap awal untuk mengetahui penyebab penyakit yang mendasariasites. Penggabungan beberapa tolok ukur memiliki kepekaan dan kekhasan yang baik dalam membedakan jenis cairan asites. Penelitianini bertujuan untuk mengetahui kesesuaian antara patokan Light dan Serum Ascites Albumin Gradient (SAAG) dalam membedakantransudat dan eksudat pada cairan asites. Penelitian ini merupakan penelitian analitik dengan desain potong lintang terhadap 24 pasienasites di RSUP Dr. M. Djamil Padang, mulai bulan Maret sampai September 2016. Tolok ukur yang diperiksa adalah protein jumlahkeseluruhan (metode kolorimetrik biuret), albumin (metode kolorimetrik bromocresol green), serta laktat dehidrogenase (LDH) (metodeenzimatik). Hasil pemeriksaan setiap tolok ukur dirumuskan kedalam patokan Light dan SAAG. Kesesuaian patokan Light dan SAAGdalam membedakan transudat dan eksudat cairan asites ditentukan dengan uji kappa. Hasil dianggap bermakna secara statistik jikap0,05). Hasil penelitian ini menyimpulkan tidak terdapat kesesuaian antara patokan Light dan SAAG dalam membedakan transudatdan eksudat pada cairan asites. Penelitian dalam jumlah besar perlu dilakukan untuk menentukan kepekaan dan kekhasan keduapemeriksaan.

Background and aim of the work: Portal hypertension (PHT) and the eventual Oesophageal varices (OV) is one of the awful complications of liver cirrhosis. Bleeding from OV is a real leading cause of death. This study aims at evaluating serum ascites albumin gradient (SAAG) as a predictor of OV. Patients and methods: A descriptive cross-sectional study was conducted on 105 males and 26 females where they were divided into two main groups and sub groups according to the presence and size of OV. All participants were subjected to full history taking, thorough clinical examination, laboratory investigations, liver function tests, complete blood count, kidney function tests, hepatitis markers: HCV-Ab (anti hepatitis c virus antibody) hepatitis B surface antigen (HBs-Ag), abdominal ultrasonography and abdominal diagnostic paracentesis with calculation of SAAG. Results: there is highly significant increased SAAG in cirrhotic patients with OV than those without. Moreover, SAAG increases significantly with the grade of O.V. Conclusion: Serum ascites albumin gradient (SAAG) could be used as a non-invasive predictor for the presence of O.V in cirrhotic patients with ascites. Moreover, SAAG value increased significantly with the progression of O.V.

// Chieh-Sheng Lu, 1, 2, 3 , Jen-Kou Lin 5, 6 , Wei-Shone Chen 5, 6 , Tzu-Chen Lin 5, 6 , Jeng-Kai Jiang 5, 6 , Shung-Haur Yang 5, 6 , Huann-Sheng Wang 5, 6 , Shih-Ching Chang 5, 6 , Yuan-Tzu Lan 5, 6 , Chun-Chi Lin 5, 6 , Hung-Hsin Lin 5, 6 , Hao-Wei Teng 3, 4, 5 1 Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan 2 Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 3 Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan 4 Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan 5 School of Medicine, National Yang-Ming University, Taipei, Taiwan 6 Division of Colon and Rectum Surgery, Department of Surgery, Taipei Veterans General Hospital & National Yang-Ming University, Taipei, Taiwan Correspondence to: Hao-Wei Teng, email: hwteng1971@gmail.com Keywords: intraperitoneal injection, ziv-aflibercept, metastatic colorectal cancer, serum ascites albumin gradient Received: May 22, 2016 Accepted: November 12, 2016 Published: November 24, 2016 ABSTRACT Ascites related to metastatic colorectal cancer (mCRC) reduces patient survival and quality of life, and systemic chemotherapy is largely ineffective for managing ascites. Here, we examined the clinical efficacy of intraperitoneal (IP) ziv-aflibercept for managing refractory ascites in 15 mCRC patients who did not respond to standard chemotherapy. Fifty or 100 mg of ziv-aflibercept in 100 mL of saline solution were infused through a pigtail catheter and retained for 24 h. When the ascites drainage volumes were subsequently monitored, 73.3% of patients showed an objective response (OR) to IP ziv-aflibercept treatment. Patients with low Eastern Cooperative Oncology Group (ECOG) performance status or with serum ascites albumin gradients (SAAG) less than 1.1 g/dL had better responses to treatment, and 4 patients with SAAG less than 1.1 g/dL showed rapid objective responses (rOR). These findings indicate that intraperitoneal ziv-aflibercept therapy may be a highly effective means of treating refractory ascites in mCRC patients, and that SAAG may be predictive of a rapid response to this treatment.

Background: Spontaneous bacterial peritonitis (SBP) is probably the best characterized infectious complication that develops in patients with cirrhosis and ascites. Aims and objective: The present study was done to find the incidence of SBP in patients of chronic liver disease and to find its correlation with serum ascites albumin gradient. Material and Methods: A total of 55 patients were selected for the study and divided into 2 groups; Group A - spontaneous bacterial peritonitis (SBP) and Group B -sterile cirrhotic ascites (SCA). Diagnosis was done by calculating SAAG (Serum Ascites Albumin Gradient) which reflects the differences in osmotic pressure and correlates with portal venous pressure. Total ascitic protein and ascitic -serum total protein ratio were taken as a diagnostic parameter for SBP. Results: Maximum incidence of disease was found between 31-50 years of age. Serum albumin values in SBP (2.50±0.31 gm/dl) when compared with SCA (2.85±0.39) and total ascites albumin in SBP (0.41±0.21) with SCA (0.89±0.31) were significantly different (p 0.05, t=1.17) was found in serum ascites albumin gradient (SAAG), when it was compared between SBP (2.09±0.42 mg/dl) and SCA (1.96±0.37 gm/dl). Conclusion: In a patient of cirrhosis with ascites early diagnosis of development of SBP in a case of SCA can prevent mortality.

Background: The etiological spectrum of ascites is vast and practically includes pathology of all the systems. In most cases ascites will appear as a part of a well-recognized illness i.e. cirrhosis, tuberculosis, congestive heart failure, nephrosis or disseminated carcinomatosis. Few patients have more than one cause of ascites formation. Majority of cases of ascites are due to portal hypertension, mainly as a result of cirrhosis. Other subset of cause includes pathology of peritoneum, which are not related to portal hypertension. A portal hypertension ascites was distinguished from the non-portal hypertension causes by determining whether the fluid is transudate or exudate. But many infected and malignancy related samples have been reported to have transudative fluid and many samples obtained from patients with cirrhosis or heart failure had exudative ascitic fluid. Hence there is a need for this study to know the efficacy of serum ascites albumin gradient and serum ascites cholesterol gradient to differentiate ascites of portal and non-portal hypertensive etiology. Ascites associated with portal hypertension has high serum - ascites albumin gradient i.e ≥1.1 gm/dl, whereas ascites associated with peritoneal inflammation or malignancy has low gradient 1.1 gm/dl is suggestive of portal hypertension not only in patients with transudative type of ascites but also in cases with high protein concentration. The Mean±SD of SACG in malignant ascites is 38.2±10.8 and in non-malignant ascites is 78.1±20.2 and is statistically significant in classifying ascites into malignant and non-malignant etiology.

Hepatic sinusoidal obstruction syndrome (SOS) has been reported in patients receiving high dose intravenous (IV) cyclophosphamide especially as a part of preparative regimen for hematopoietic stem cell transplantation. Hepatic SOS from low dose oral cyclophosphamide has not been reported. Here we present a rare case of hepatic SOS induced by low dose oral cyclophosphamide. A 78-year-old male with history of coronary artery disease status post coronary artery bypass graft (CABG) was initially seen in hematology clinic for evaluation of normocytic anemia. During workup, bone marrow biopsy revealed NK cell large granular lymphocytic leukemia (LGL). He was then started on low dose oral cyclophosphamide 50 mg daily. After 2 months, his dose was reduced to 25 mg daily due to severe neutropenia. He then tolerated cyclophosphamide well and his hemoglobin (Hb) improved from his baseline 8 gm/dl to 12 gm/dl in 4 months. After 6 months of treatment, he was admitted to the hospital for abdominal distension, ascites and 15 pounds weight gain over 3 weeks. Labs most prominent on admission were Hb of 12.5 gm/dL , WBC 5.3 x 103/µL, Platelets 197 x 103/µL, total bilirubin 1.6 mg/dL, aspartate aminotransferase (AST) 89 U/L , alanine aminotransferase (ALT) 35 U/L and alkaline phosphatase (ALP) 283 U/L. Workup of ascites included abdominal paracentesis which revealed serum ascites albumin gradient(SAAG) High dose of IV cyclophosphamide given as myeloablative therapy in combination of total body irradiation or busulfan (or other agents) in preparation for hematopoietic stem cell transplantation can induce hepatic SOS, which can be severe leading to acute liver failure and death. The diagnosis is usually based on clinical features of tender hepatomegaly, weight gain, ascites and jaundice. Liver biopsy is usually diagnostic. Mechanism of injury is related to direct toxic effects of cyclophosphamide on sinusoidal cells in the liver, causing their necrosis and release into the sinusoids, obstruction and obliteration of hepatic veins. This case demonstrates that hepatic SOS can also be caused by low dose oral cyclophosphamide. Given this rare occurrence, it is prudent for the clinicians to keep an open mind and consider hepatic SOS as a potential side effect even with oral cyclophosphamide. Disclosures Yacoub: Novartis: Speakers Bureau; Agios: Honoraria, Speakers Bureau; Incyte: Speakers Bureau; Hylapharm: Current equity holder in private company; Cara Therapeutics: Current equity holder in publicly-traded company; Ardelyx: Current equity holder in publicly-traded company; Dynavax: Current equity holder in publicly-traded company; Roche: Other: Support of parent study and funding of editorial support.

INTRODUCTION: Nivolumab, a monoclonal antibody immune checkpoint inhibitor (ICI) acting on PD-1, is an effective treatment for many malignancies The augmentation of T cell immunity leads to its therapeutic effect, yet commonly causes immune-related adverse effects (irAE) ICI-induced diarrhea is frequently reported, while other gastrointestinal irAE are less well described Here, we report a case of nivolumab-induced eosinophilia, ascites, and abdominal pain CASE DESCRIPTION/METHODS: A 58-year-old man with a history of tobacco use and stage IIB lung adenocarcinoma status post partial lobectomy, adjuvant chemotherapy (platinum/pemetrexed), and nivolumab was admitted with 1 month of diffuse abdominal pain and distention, dyspnea, fatigue, and intermittent low-grade fevers He had received 11 cycles of nivolumab over 9 months, but it was stopped 3 months before admission due to eosinophilia On admission, temperature was 99 4 and he had mild sinus tachycardia Initial labs were notable for WBC 22 6 (3 5% bands), absolute eosinophil count 1605 (peak 4563), and platelets 800 CT chest/abdomen/pelvis revealed hepatomegaly, new ascites, and bilateral pleural effusions Paracentesis indicated inflammatory ascites (serum ascites albumin gradient 0 5) Infectious work-up was negative, including COVID-19 testing ECHO showed normal cardiac function and small pericardial effusion He received empiric antibiotics without improvement EGD revealed mild diffuse duodenal lymphangiectasia Duodenal biopsies showed patchy villous blunting with inflammatory infiltrate, including eosinophils within the lamina propria After extensive work-up and multidisciplinary consultation, nivolumab-induced eosinophilia with serositis was diagnosed Empiric high dose steroids (solumedrol) and ivermectin/ albendazole were given, though parasitic infection deemed unlikely After symptoms improved, he was discharged on a prednisone taper DISCUSSION: In this patient presenting with a constellation of symptoms, nivolumab-associated eosinophilia with serositis was the unifying diagnosis, causing the atypical GI symptoms of new ascites and abdominal pain While rare, eosinophilia has been reported with ICI use (1) Thus, irAE must be considered in a patient with new GI symptoms after ICI therapy, as treatment with steroids and/or biologics may be indicated (Figure Presented)

Background The diagnostic value of ascitic cholesterol in the differential diagnosis of ascites is controversial. Aim To investigate the diagnostic performance of ascitic cholesterol in the differential diagnosis of ascites. Methods Consecutive patients with new-onset ascites were enrolled prospectively. The pertinent data were collected from 629 patients with all forms of ascites. Results In the training cohort, determination of the ascitic cholesterol level was a highly effective method of distinguishing non-portal hypertension (NPH) from portal hypertension (PH). At the pre-determined cut-off value of 45 mg/dL, the sensitivity of ascitic cholesterol was superior to the serum-ascites albumin gradient (SAAG) in identifying NPH-related ascites; the area under the receiver operating characteristic curve was 0.945. In the patients misdiagnosed based on SAAG classification, the diagnostic accuracy of ascitic cholesterol was 69%. The ascitic cholesterol level showed excellent performance in identifying peritoneal lesions in patients with mixed ascites. Conclusion Ascitic cholesterol is an excellent measure for detecting NPH ascites and for identifying peritoneal lesions in mixed ascites. Thus, this simple and cost-effective measure should be determined in patients with new-onset ascites (www.chictr.org.cn; ChiCTR-DCD-15006907).

A 67-year-old male with history of well controlled type 2 diabetes mellitus and hypertension developed acute interstitial nephritis (AIN) with nephrotic-range proteinuria during treatment with cefazolin for methicillin-sensitive Staphylococcus aureus and Group B Streptococcus (GBS) bacteremia. The patient received intravenous cefazolin 2 g every 8 h for 4 weeks prior to presentation to the emergency department with abdominal distension, nausea, and vomiting. Investigations revealed a serum ascites albumin gradient of 1.0 with total protein of 1.8 g/dL suggestive of nephrotic syndrome, which was confirmed with a spot urine protein/creatinine ratio that estimated 7.95 g of protein per day. Serum creatinine was elevated compared with baseline. Urine studies showed sterile pyuria with 3+ protein and eosinophiluria. The patient was diagnosed with AIN with nephrotic-range proteinuria associated with cefazolin use. Cefazolin was discontinued and, within a couple of days, the patient’s creatinine stabilized. He was discharged with prednisone 60 mg once a day for 10 days with a taper over 2 weeks for his AIN. The patient’s creatinine and proteinuria slowly decreased over the next couple of weeks, however, did not recover to baseline. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient’s AIN with nephrotic-range proteinuria and his use of cefazolin.

Background At our center, we observed a series of patients who developed transudative refractory ascites secondary to non-cirrhotic non-veno-occlusive disease (NC-nVOD) portal hypertension after allogeneic transplant (allo-SCT). The natural history, pathogenesis and etiology of this phenomenon is not well characterized nor well studied in the literature. Objectives To study and analyze the clinical characteristics and outcome of myeloid and lymphoid malignancy patients who developed IPHRA post allo-HCT. Methods In this retrospective study, we analyzed age>18 myeloid and lymphoid malignancy patients who developed IPHRA post allo-HCT. IPHRA was defined as NC-nVOD intrahepatic portal hypertension (serum ascites albumin gradient ≥ 1.1 or hepatic venous pressure gradient (HVPG) >5) and related refractory ascites in the absence of pre and post-hepatic etiologies of portal hypertension. Results We identified 24 patients who developed IPHRA post allo-HCT from our database. Median age at the time of allo-HCT was 52 yrs (range, 23-67). 23/24 did not have elevated LFT (Transaminases> 2.5 ULN/Bilirubin>1.5 ULN) before allo-HCT. Median time to development of IPHRA after allo-HCT was 95 days (range, 21-576 days). A median number of paracentesis that these patients had was 2 (range, 1-11); 5 had an intraperitoneal catheter placed, and 2 had TIPS to decrease the portal pressure. Portal pressures were measured in 15 patients, 9 had moderate portal hypertension (HVPG 5-10), and 6 had severe portal hypertension (HVPG >10). Liver biopsy was done in 20 patients, and for 3 patients we had autopsy results available. None of the patients met either the histological or clinical criteria of VOD or cirrhosis. 19 patients (79 %) died, and the median survival after development of IPHRA was 5.2 months (range, 0.7-49). The most common cause of death were complications of ascites/liver failure (n=7, 37%), and infectious causes (n=7, 37%). Conclusion IPHRA is an unrecognized fatal entity post-allo-HCT and has a high mortality rate. Further investigation is necessary to establish prognostic criteria for patients at risk of this serious complication.

Introduction: Various studies have demonstrated superiority of SAAG (serum ascites albumin gradient) in classifying ascites compared to transudate-exudate concept but with conflicting observations. Ascitic fluid total protein (AFTP) level in ascitic fluid is a much cheaper alternative to the serum ascites albumin gradient ratio. Hence in the study, we have compared the diagnostic accuracy of the old cheaper traditional method against the new method. Methods: Total 102 patients of Ascites were included in the study from J.A. group of hospital, G.R.Medical College (M.P.) in year 2013-15. All medical causes of ascites were included in our study and Non medical causes were excluded. The collected data was analyzed by using Pearson Chi-square statistical analysis to determine correlation between variables. Result: For prediction of liver disease it was found that SAAG was significantly (p value 0.0341) more predictive of Liver disease compared to AFTP. SAAG (p value

Objective: To evaluate the capability of ascitic fluid dipstick results for pH, glucose, and protein in order to predict a low serum-ascites albumin gradient (SAAG) at the bedside of the patient in the emergency department (ED). Methods: This prospective cross-sectional study was conducted during one year in the ED of Afzalipour hospital in Kerman, Iran. All patients with diagnostic or therapeutic paracentesis of ascitic fluid were considered as eligible patients. Exclusion criteria included clinical suspicion for spontaneous bacterial peritonitis (SBP), any contraindications to paracentesis, and patients’ refusal to participate in the study. Dipstick values were obtained at the bedside, and SAAG was calculated after the determination of serum and ascitic fluid albumin by laboratory. A low SAAG ascitic fluid was defined as the study outcome. We also used our study population as a test group to evaluate an equation proposed in one previous study: K = 0.012 Protein−0.012 Glucose−3.329 pH+23.498 Results: A total of 50 patients were enrolled in the study. Based on multivariate regression analysis, dipstick values for protein and glucose were independently predictive of a low SAAG ascitic fluid (P = 0.23, OR = 1.04; and P = 0.001, OR = 0.81, respectively). The formula proposed in one of the previous studies was tested by our data set, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at 84%, 83%, 84%, and 80%, respectively. Conclusion: Dipstick test of ascitic fluid for pH, glucose, and protein has an acceptable sensitivity and specificity as a point of care test, but it cannot be recommended as a substitute for SAAG determination based on the current findings.

Ascites is the pathological state in which fluid accumulates in the peritoneal cavity. Fluid accumulation may be due to infection and malignancy or due to other diseases like liver disease, heart failure, and renal disease. The ascitic fluid can be graded into Transudative and Exudative fluid based on the serum ascites albumin gradient (SAAG). The prominent cause of ascites is found to be Liver Cirrhosis. The most common symptom of Ascites is recent weight gain, increased abdominal girth and dyspnea. The first line treatment of ascites includes education regarding dietary sodium restriction and oral diuretics. However, other mechanical methods can also be used if the patient is unresponsive to this approach. But, there are some limitations while using these mechanical methods. Ascites is also associated with certain complications like spontaneous bacterial perotinitis, hepatorenal syndrome and dilutional hyponatremia. Ascites itself is not fatal unless it becomes infected. So, early diagnosis and effective treatment should be ensured in order to avoid further complications. This review focuses on the grades, causes, symptoms, management and complications of Ascites.DOI: http://dx.doi.org/10.3329/icpj.v4i3.21936 International Current Pharmaceutical Journal, February 2015, 4(3): 370-377

Background: Ascites is pathological accumulation of free fluid in the peritoneal cavity. Appropriate management for ascites depends upon diagnosis of its etiology. Based on total protein concentration of ascitic fluid, earlier ascites was classified as transudate and exudate. The present study was designed to compare the utility of total protein, lactate dehydrogenase (LDH) and serum ascites albumin gradient (SAAG) to categorise ascitic fluids as either exudate or transudate. Methods: This prospective study comprised of 110 adult patients with ascites whose diagnosis was established by clinical examination and appropriate investigations. Biochemical analysis of ascitic fluid and serum was done with protein, albumin and LDH. The usefulness of each biochemical parameters was statistically evaluated in terms of sensitivity, specificity, accuracy, PPV and NPV. Results: In this endeavour, the SAAG and fluid LDH did showed a clear advantage over the fluid protein which is traditional existing biochemical parameter for differential diagnosis of ascitic fluid into transudate and exudate. Conclusions: The SAAG had more discriminatory power than fluid protein parameter and hence should replace fluid protein test in diagnostic separation of ascites into transudate and exudate.

Background and aims As liver cirrhosis is a dynamic condition, it is possible to improve survival in decompensated cirrhosis. Hence, we planned a prospective study to determine the natural history of cirrhosis after first decompensation. Methods We enrolled all patients of liver cirrhosis who presented with first episode of decompensation defined by the presence of ascites, either overt or detected by Ultrasonography (UD), Gastroesophageal Variceal Bleeding (GEVB), and Hepatic Encephalopathy (HE). All patients were followed up to death/liver transplant or at least for the period of 1 year. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or Orthotopic Liver Transplantation (OLT)). Results In total of 110 cirrhotic patients (93 males, mean age 50 ± 11 years), the most frequent etiology was alcohol (48%), followed by nonalcoholic steatohepatitis/cryptogenic (26%), hepatitis B (10%), autoimmune hepatitis (7%), and hepatitis C (6%). The distribution of CTP classes was: 4%, 56%, and 41% in class A, B, and C, respectively. Ascites was the most common decompensation found in 88 patients (80%) followed by HE (14%) and GEVB (6%). At 1-year follow up, transplant free survival was 78%, 2 underwent OLT, 4 developed hepatocellular carcinoma, and 24 died. Cumulative incidence of failure (death or OLT) by type of decompensation after 1 year was: 22% overt ascites, 50% GEVB, 28% UD ascites, 20% HE, and 33% ascites and GEVB concomitant. Conclusions Patients with UD ascites do not have a negligible mortality rate as compared to overt ascites. Patients with cirrhosis after first decompensation have better transplant free survival with treatment of etiology and complications than previously mentioned in literature.