High serum-ascites albumin gradient in a patient with chronic liver disease and peritoneal tuberculosis

A serum ascites albumin gradient (SAAG) ≥ 1.1 g/dl is 97% accurate in identifying ascites due to portal hypertension. Peritoneal tuberculosis is a cause of low SAAG ascites. We report a patient with decompensated advanced chronic liver disease (d-ACLD) and peritoneal tuberculosis who had an SAAG of more than 1.1 g/dl. A 48-year-old Sri Lankan male presented with low-grade fever with constitutional symptoms and progressive abdominal distention for 3 months. He had diabetes mellitus and d-ACLD secondary to alcohol abuse. The initial evaluation for common infective, neoplastic, and inflammatory causes of prolonged fever was unremarkable. The initial ascitic fluid SAAG was 1.1 g/dl, which increased to 1.3 g/dl after 2 weeks. The fluid was lymphocytic. Laparoscopy revealed an inflamed peritoneum with fibrinous strands extending from the peritoneal surface to the abdominal viscera. The peritoneal biopsy showed granulomatous inflammation with caseous necrosis, and PCR detected mycobacterial DNA. The patient was treated with anti-tuberculous therapy but succumbed to hepatic decompensation. In the presence of d-ACLD, peritoneal tuberculosis can cause ascites with an SAAG ≥ 1.1 g/dl. However, peritoneal tuberculosis cannot be ruled out by biochemical analysis alone in patients with d-ACLD—a high SAAG results from diluting the exudate by water retained in liver disease.