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50 year old Chinese man with worsening abdominal distention (Fluid-->…

- - - - Alcoholic hepatitis: hx of excessive drinking, jaundice, abdominal discomfort, nausea; Exam: jaundice, tender hepatomegaly, hepatic bruit, spider angiomas, palmar erythema, signs of hepatic encephalopathy. Hepatitis C: blood/body fluid exposure (e.g., hx drug use, blood transfusion); Exam: jaundice.
    - - Peritoneal carcinomatosis (10%): hx of underlying gastrointestinal, lung, or breast malignancy or malignant melanoma; Exam: periumbilical lymph nodes, positive stool occult blood (GI cancer), hepatic bruits (hepatocellular carcinoma). Heart failure (3%): exertional dyspnoea, fatigue limiting exercise tolerance, leg swelling, abdominal swelling, HTN, diabetes, valvular heart disease, smoker, FHx sudden cardiac death, MI, stroke, peripheral arterial disease, hx chest pain, ; Exam: peripheral oedema, rales, dyspnoea, jugular venous distention, cool extremities, narrow pulse pressure, pleural effusions. Tuberculosis (2%): residence in/visit to high-prevalence area, close contact with active TB; hx of anorexia, malaise, weight loss, fever, or night sweats; chronic cough productive of sputum, occasionally associated with haemoptysis; immunosuppressed (AIDS) Exam: fever, cachexia, tachycardia; asymmetry in chest movement and dullness to percussion due to pleural effusion, bronchial breathing, crackles, rales due to an infiltrate or rhonchi in presence of significant bronchial purulence; palpable extra-thoracic lymphadenopathy is uncommon.
  - - - SAAG ≥1.1 g/dL --> portal hypertension.
        
        ascitic protein level of ≥2.5 g/dL ---cardiac ascites (high BNP), early Budd-Chiari syndrome, IVC obstruction or sinusoidal obstruction syndrome.
        
        ascitic protein level <2.5 g/dL --- cirrhosis, late Budd-Chiari syndrome, or massive liver metastases
      - SAAG <1.1 g/dL
        
        tuberculous peritonitis, peritoneal carcinomatosis, or pancreatic ascites.
    - - Turbid fluid -- infection or tumor cells. White, milky fluid--TG level >200 mg/dL (and often >1000 mg/dL), which is the hallmark of chylous ascites--steatorrhoea. Chylous ascites results from lymphatic disruption that may occur with trauma, cirrhosis, tumor, tuberculosis, or certain congenital abnormalities. Dark brown fluid --high bilirubin conc due to biliary tract perforation. Black fluid --pancreatic necrosis or metastatic melanoma.