SerumAscites Albumin Gradient

1
Serum-Ascites Albumin Gradient

• Vernesha Montgomery
• MS3

2
Ascites

• Ascitic Fluid Tests Is the fluid infected? Is
  Portal Hypertension Present?
• Appearance (clear, bloody, milky etc)
• Cell Count and Differential- begin antibiotics if
  PMN count 250,000
• Cultures- Inoculate bottles _at_bedside
• SAAG- Serum-Ascites Albumin Gradient

3
SAAG

• Formula Serum Albumin minus Ascitic Albumin
• SAAG Accurately identifies the presence of
  portal hypertension

4
Literature

• 1983- Gastroenterology- prospective study of
  28/29 patients with liver disease with increased
  portal htn and increased gradient , and 14/15
  patients with malignant neoplasm, decreased
  Portal htn, and decreased gradient
• 1988-Digestive Diseases and Sciences- 94 patients
  with Ascites from different etiologies (CLD,
  Malignancy, CHF, hypothyroidism). Comparisons of
  Ascitic and Serum Fluid. Analysis SAAG gradient
  better indicator of portal hypertensive ascites

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Best Evidence

• 1992 Annals of Internal Medicine
• The Serum Ascites Albumin Gradient Is Superior to
  the Exudate-Transudate Concept in the
  Differential Diagnosis of Ascites
• -Challenged the Exudate-Transudate Concept
  Ascitic Fluid Total Protein 2.5g/dl exudative
  and Ascitic Fluid Total Protein transudative
• -Prospective study to compare SAAG with total
  protein ratio
• -901 paired serum/ascitic fluid samples (max 30
  minutes apart) from 330 consecutive patients with
  confirmed diagnosis
• -Portal Hypertension ( wedged pressure-IVC.4mmHg,
  varices by scope biopsy for cirrhosis or ETOH
  hepatitis autopsy
• -97 Accuracy using 1.1 g/dl
• -Gradient Not affected by diureses, paracentesis,
  alcohol vs. non alcoholic liver disease
• -Other tests have lower Specificity and
  Sensitivity and should be ordered based on
  Clinical Suspicion rather than routinely

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E.N.

• Peritoneal Fluid
• -Seg 49
• -WBC 345
• -PMN 169 (ruled out SBP)
• SAAG
• No growth on cultures
• Cytology no malignancy
• Patient had clinical picture of Right Sided Heart
  Failure
• Exception, we would expect SAAG 1.1 for CHF

7
References

• Pare P, Talbot J, Hoefs J. Serum-Ascites Albumin
  Concentration Gradient A physiologic Approach to
  the Differential Diagnosis of Ascites.
  Gastroenterology 1983 85 240-4
• Mauer K, Manzione N. Usefulness of Serum-Ascites
  Albumin Difference in Separating Transudative
  from Exudative Ascites-Another Look. Digestive
  Diseases and Sciences 1988 331208
• Runyon BA, Montano AA, Evangelos AA, Mainor RA,
  Irving MA, McHutchinson JG. The Serum-Ascites
  Albumin Gradient Is Superior to the
  Exudate-Transudate Concept in the Differential
  Diagnosis of Ascites. Annals of Internal Medicine
  1992 116 215-222
• Runyon BA. Cardiac Ascites. Journal of Clinical
  Gastroenterology 1988 10 (4) 410-12