A 40-year-old man with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical examination, there are spider angiomas and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. Which of the following is the most important first step in the patient’s evaluation?
a. Diagnostic paracentesis
b. Upper GI series
c. Ethanol level
d. CT scan of the abdomen
e. Examination of peripheral blood smear
Answer
The answer is a.
Paracentesis is required to evaluate new-onset ascites. While cirrhosis and portal hypertension are most likely in this patient, complicating diseases such as tuberculous peritonitis and hepatoma are ruled out by analysis of ascitic fluid. An ultrasound or CT scan can be used to demonstrate ascitic fluid in equivocal cases. A serum albumin minus ascitic fluid albumin greater than 1.1 suggests portal hypertension alone as a cause for ascites. Tuberculosis, pancreatitis, and malignancy would cause inflammation and increased capillary permeability, causing protein to leak into the ascitic fluid. This would result in a gradient between the serum and ascitic fluid of less than 1.1. Upper GI radiographs are less useful than endoscopy in demonstrating the esophageal varices that may be associated with cirrhosis. Neither serum ethanol level nor an evaluation of the peripheral blood smear for evidence of folate deficiency would specifically address the ascites.
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Gastroenterology
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