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

Last Updated: June 24, 2012

Learning Objectives

A 45-year-old male patient with chronic hepatitis C infection (genotype 2) is receiving peginterferon and ribavirin therapy. Prior to treatment he was noted to have well-compensated cirrhosis. Eight weeks into treatment the patient develops worsening hepatic function, with increased total bilirubin, a decreased serum albumin level, and an increased prothrombin time (international normalization ratios [INR] of 1.6). He was also noted to have a low-grade fever and a distended, tender abdomen. “Shifting dullness” is observed on examination and an abdominal ultrasound confirms a moderate amount of ascites. The hepatitis C treatment is immediately stopped.

What one of the following would you recommend in the initial evaluation of this patient’s new-onset ascites?

	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.
	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).
	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).
	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).