A 41-year-old man comes to the office due to abdominal pain and distension. Over the past 2 months, the patient has noted constant, gnawing epigastric pain that intensifies after meals. More recently, his abdomen has become progressively enlarged and uncomfortable. The patient has been admitted to the hospital multiple times due to alcohol-related intoxication and seizures. He does not use tobacco or intravenous drugs. Family history is unremarkable. Temperature is 37.7 C (99.9 F), blood pressure is 132/78 mm Hg, and pulse is 80/min. Mental status is normal, and cardiopulmonary examination is unremarkable. The abdomen is grossly distended and mildly tender to palpation in the epigastric region. Shifting dullness is present. A diagnostic paracentesis is performed, which reveals serosanguinous fluid. Analysis of this fluid shows high levels of both total protein and amylase. Serum albumin is 3.4 mg/dL. Which of the following is the most likely explanation for this patient's presentation?
Ascitic fluid characteristics | |
Gross appearance |
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Serum-to-ascites |
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Total protein |
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Cell count |
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HTN = hypertension; SBP = spontaneous bacterial peritonitis; TB = tuberculosis. | |
This patient with chronic alcohol misuse and epigastric pain that worsens postprandially, suggestive of chronic pancreatitis, has now developed ascites (eg, abdominal distension, shifting dullness) with high amylase and total protein, most consistent with pancreatic ascites.
Chronic pancreatitis most commonly occurs in patients with chronic alcohol use disorders. Initial symptoms include constant epigastric pain that intensifies with meals as well as nausea and vomiting; signs of exocrine insufficiency (eg, steatorrhea, fat-soluble vitamin deficiency) and diabetes mellitus usually develop later. Pancreatic ascites is a rare complication of chronic pancreatitis that results from damage to the pancreatic duct, leading to leakage of pancreatic juice into the peritoneal space. Like ascites from other causes, symptoms include abdominal distension, weight gain, dyspnea, and early satiety. Examination findings include shifting dullness and a fluid wave.
Ascites in chronic pancreatitis is often identified by imaging (eg, ultrasound, CT scan). A diagnostic paracentesis should be performed to confirm the etiology. Pancreatic ascites is typically serosanguinous or straw-colored with analysis showing high amylase (often >1000 U/L), high total protein (≥2.5 g/dL), and low serum-ascites albumin gradient (SAAG) (<1.1, indicating the absence of portal hypertension).
(Choice A) Ascites from cirrhosis is straw yellow with normal amylase, low total protein, and high SAAG. In addition, patients with cirrhosis usually have a low serum albumin due to hepatic synthetic dysfunction.
(Choice B) Budd-Chiari syndrome (ie, hepatic venous obstruction) can cause ascites but it is usually straw yellow with normal amylase, high total protein, and high SAAG. Patients typically have severe right upper quadrant pain with jaundice, hepatic encephalopathy, and possibly variceal bleeding.
(Choice C) Hepatocellular carcinoma can present with malignant ascites, which is typically bloody (not serosanguinous) with normal amylase, high total protein, and low SAAG.
(Choice D) Ascites from intestinal perforations have high polymorphonuclear neutrophil counts (≥250 cells/mm3), low glucose, high lactate dehydrogenase, normal amylase, high total protein, and low SAAG. In addition, perforation typically causes sudden, severe pain associated with fever and leukocytosis.
(Choice E) Lymphomas can cause lymphatic obstruction and chylous ascites, which is milky with high triglyceride levels. Normal amylase, high total protein, and low SAAG are expected.
Educational objectives:
Chronic pancreatitis occurs most commonly in patients with chronic alcohol use disorders and results in postprandial epigastric pain. Pancreatic ascites results from damage to the pancreatic duct with leakage of pancreatic juice into the peritoneal space. Paracentesis findings include serosanguinous or yellow fluid with high amylase, high total protein, and low serum-ascites albumin gradient.