Snap Shot A 65-year-old man presents to the emergency department with worsening abdominal distention. He has a long history of alcohol abuse. On physical exam, shifting dullness and a fluid wave is present. An image of his abdomen is given. Introduction Peritoneal edema as a result of portal hypertension hypoalbuminemia Presentation Symptoms abdominal distention Physical exam shifting dullness fluid wave Evaluation Paracentesis send ascitic fluid for WBC count, gram stain, culture, glucose, protein Serum Albumin Ascites Gradient (SAAG) SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid) if > 1.1 g/dL) indicates the ascites is due to portal hypertension with 97% accuracy if < 1.1 g/dL indicates causes of ascites not associated with increased portal pressure Treatment Order of treatment involves salt and water restriction limit to approximately 2 L per day diuretic therapy spironolactone loop diuretic added ascitic fluid taps 2-4 L drained often with albumin infusion during procedure Prognosis, Prevention, and Complications Complications hepatorenal syndrome severe complication result from over aggressive diuresis or tapping spontaneous bacterial peritonits check peritoneal fluids for infection and treat with broad spectrum antibiotics diagnosis made by > 500 PMNs in the peritoneal fluid glucose is low and protein is high with bacterial peritonitis abdominal hernias