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A 58-year-old man is referred with three weeks of progressive abdominal distension and bilateral ankle swelling. He has drunk around 60 units of alcohol per week for two decades. On examination he has spider naevi, palmar erythema and gynaecomastia, with shifting dullness on percussion. He is afebrile and reports no abdominal pain.
A diagnostic ascitic tap is performed, with a serum albumin taken the same day:
| Investigation | Result |
|---|---|
| Ascitic appearance | Clear, straw-coloured |
| Ascitic albumin | 8 g/L |
| Serum albumin (same day) | 30 g/L |
| Ascitic total protein | 14 g/L |
| Ascitic neutrophils | 90 cells/mm³ |
Which is the single most likely underlying cause of his ascites?
SAAG = serum albumin − ascitic albumin = 30 − 8 = 22 g/L. A high gradient (≥ 11 g/L) means portal hypertension; the stigmata of chronic liver disease point to cirrhosis.
The serum–ascites albumin gradient (SAAG) is the single most useful test for classifying ascites. Here SAAG = 30 − 8 = 22 g/L. A gradient of ≥ 11 g/L indicates portal hypertension, and the alcohol history plus spider naevi, palmar erythema and gynaecomastia make cirrhosis the cause. A low ascitic total protein (< 25 g/L) fits a transudative cirrhotic picture, and a neutrophil count < 250 cells/mm³ excludes infection.
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