Exudative v/s transudative ascites: differentiation based on fluid

echogenicity on high resolution sonography.

HM Malde, RD Gandhi
Dept of Radiology, KEM Hospital, Parel, Bombay, Maharashtra.,
Correspondence Address:
H M Malde
Dept of Radiology, KEM Hospital, Parel, Bombay, Maharashtra.
:: Abstract
Real time sonography was performed in 52 patients with ascites to evaluate the accuracy of
sonography in differentiating an exudative from a transudative collection. The echogenicity
of ascites was graded I, II and III using the echogenicity of normal abdominal viscera as
comparative standard reference points. Grade I collections (31 patients) were either
absolutely anechoic, or showed few internal echoes secondary to particulate matter. Grade II
collections (7 patients) were hypoechoic as compared to the liver and spleen. Grade III
collections (14 patients) had an echogenicity similar to or greater than that of the liver and
spleen. The results of diagnostic aspiration in all patients were then compared to the
sonographic grade of the ascitic fluid. All transudates (28 patients) had a Grade I
echogenicity. Only 3 patients with an exudative ascites had a Grade I echogenicity. The
remaining 21 patients with an exudative collection had an echogenicity equal to or greater
than Grade II. Using these results, an ascitic fluid echogenicity of Grade I had a 92.32%
sensitivity, 100% specificity, a positive predictive value of 1 and a negative predictive value
of 0.875 in diagnosing transudates. An ascitic fluid echogenicity of Grade II or more had a
sensitivity of 87.5%, specificity of 100%, a positive predictive value of 1 and a negative
predictive value of 0.903 in diagnosing transudates.

Keywords: Adult, Ascites, etiology,ultrasonography,Diagnosis, Differential, Female, Human,

Liver
Cirrhosis,
complications,ultrasonography,Male,
Tuberculosis,
Peritoneal,
complications,ultrasonography,
Introduction
Cirrhosis and abdominal tuberculosis are amongst the commonest causes of ascites in our
country. As ultrasonography (USG) is the primary radiological investigation in these
patients, the ability to distinguish transudative from exudative ascites using this modality,
would obviously simplify the further diagnostic work-up and management off these
patients. An attempt was made using current, high resolution sonographic equipment, to
distinguish exudative from transudative ascites based on the echogenicity of the fluid.
Methods
Fifty-two patients with ascites (42 males and 10 females; mean age - 37 yrs) were subjected
to real-time sonography using one of the new generation high resolution ultrasound

equipment (Sonoline AC, Siemens Inc. Germany). A routine (3.5 MHz) sector transducer was
followed by a high frequency (7.5 MHz) transducer, to compare the echogenicity of the
ascites with the echogenicity of the normal abdominal viscera, and based on this, these fluid
collections were graded as:
Grade I : anechoic (may show few internal echoes due to floating particulate matter).
Grade II : hypoechoic as compared to the liver and spleen.
Grade III : echogenicity similar to or slightly greater than that of the liver and spleen.
The sonographic appearance of the fluid collection in each patient was then compared with
the findings of diagnostic aspiration.
Results
Twenty-eight of the 52 patients reveafed a transudate on biochemical examination of the fluid
obtained at diagnostic aspiration. The echogenicity of the ascitic fluid on sonography in each
of these 28 patients was of Grade I.
The other 24 patients had an exudative collection as determined by the results of diagnostic
aspiration. Twenty-one of these 24 patients had shown on sonography, echogenicity of Grade
II or Grade III, while in 3 of 24 ascitic fluid showed a Grade I echogenicity.
A statistical analysis of our results show that an ascitic fluid echogenicity of Grade I has a
sensitivity of 90.32%, specificity of 100%, positive predictive value of I and a negative
predictive value of 0.875 in diagnosing transudates. An ascitic fluid echogenicity of Grade II
or Grade III has a sensitivity of 87.5%, specificity of 100%, positive predictive value of 1
and a negative predictive value of 0.903 in diagnosing exudates.
Discussion
The evaluation of a patient with ascites requires that the cause of the ascites be established. A
useful framework for the work-up starts with an analysis of whether the fluid is an exudate or
a transudate. This distinction is necessary even when the cause of the ascites seems
obvious[1]. Diagnostic paracentesis thus, remains the investigation of choice for the routine
evaluation of a patient with ascites.
Over the past 2 decades, sonography has revolutionized the work- up of these patients. Apart
from guiding diagnostic aspirations, especially of small fluid collections, USG also
frequently demonstrates the causative factor responsible for their occurrence (e.g. cirrhosis,
hepatoma etc.). However, the utility of sonography in differentiating transudates from
exudates has remained variable[2],[3],[4],[5]. Several ancillary findings have been suggested
including the presence of fixed or mobile fibrinous strands and septations, fluid loculation,
mesenteric thickening with adherent small bowel loops, hepatomegaly with or without
distinct hepatic metastases, splenomegaly, lymphadenopathy, ileal wall thickening and diffuse
thickening of the greater omenturn for differentiating the exudates ascites from a transudative
one[2],[3],[4],[5]. However, they are unfortunately absent in a significant proportion of these
patients. In fact, a recent study on a large number of patients with tuberculous peritonitis of
the wet- ascitic type[3] reports that none of these findings were present in 52% of patients

with an exudative ascites. This clearly outlines the need for more sensitive sonographic
criteria to aid the differentiation of exudative from transudative ascites. In addition, we feel
that the poor resolution of the older US equipment along with the complex and subjective
sonographic criteria used by previous investigators compounded these difficulties.
We conclude from our present study, using the newer generation of high resolution US
equipment, coupled with simple and objective grading criteria, that the echogenicity of the
ascitic fluid can be a very useful predictive factor in differentiating exudates from
transudates.
References
1.
2.
3.
4.
5.

Glickman RM, Isselbacker KJ Abdominal swelling and ascites. InWilson JD, Braunwald
E, et al Eds. Harrison's Principles of Internal Medicine, 12th ed. New York: Mcgraw-Hill
Inc; 1991, pp 270-271.
Edell SL, Gefter WB. Ultrasonic differentiation of types of ascitic fluid. AJR 1979;
133:111-114.
Lee DH, Lim JH, Ko YT, Yoon Y. Sonographic findings in tuberculous peritonitis of
wet-ascitic type. Clin Radiol 1991; 44:306-310.
Vincent LM. The Peritoneal cavity and abdominal wall. In: Mittelstaedt CA, editor.
Abdominal Ultrasound. New York: Churchill Livingstone; 1987, pp 501-564.
Weill FS. Ultrasound Diagnosis of Digestive Diseases, 3rd ed. Berlin: Springer-Veriag;
1990, pp 255-294.