Evaluation of New Onset Ascites in a Patient with Chronic Hepatitis C

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D Perform a diagnostic abdominal paracentesis and obtain the following studies on the ascitic fluid: cell count and differential, total protein, albumin, and cancer antigen CA 125. In addition, calculate the serum-ascites albumin gradient (SAAG).

This answer is incorrect. A diagnostic abdominal paracentesis should be performed in all patients with new onset ascites. Although testing for ascitic fluid cell count and differential, protein, albumin, and calculation of the serum-ascites albumin gradient (SAAG) are appropriate initial tests for evaluate new onset ascites, the cancer antigen CA 125 should not be measured in ascites fluid. It is elevated in essentially all patients with ascites. Checking CA 125 in women is especially problematic in this setting, since an elevated CA 125 will lead to unnecessary gynecologic evaluation looking for ovarian cancer. In addition, considering the patient’s fever, culture is indicated to evaluate for spontaneous bacterial peritonitis and to identify the causative organism if infection is present.

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A The most valuable test to perform in this setting is an abdominal computed tomographic (CT) scan. A diagnostic paracentesis is not indicated since the procedure has a very high risk and is unlikely to yield useful information.
B Perform a diagnostic abdominal paracentesis, but the patient must receive fresh frozen plasma prior to the procedure because his prothrombin time is increased (INR = 1.6).
C Perform a diagnostic abdominal paracentesis and obtain the following studies on the ascitic fluid: cell count and differential, total protein, albumin, and culture. In addition, calculate the serum-ascites albumin gradient (SAAG).

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