Differential Diagnosis for Massive Ascites with Low SAAG and High Total Proteins

• Single most likely diagnosis:
  • Tuberculosis (TB): The combination of low SAAG (Serum-Ascites Albumin Gradient) and high total proteins in the ascitic fluid is suggestive of a non-cirrhotic cause of ascites, with TB being a common cause of ascites with these characteristics, especially in regions where TB is prevalent.
• Other Likely diagnoses:
  • Budd-Chiari Syndrome: This condition, characterized by hepatic vein thrombosis, can present with ascites and may have a low SAAG with high protein levels in the ascitic fluid due to the obstruction of hepatic venous outflow.
  • Malignancy: Various cancers can cause ascites with low SAAG and elevated protein levels, either by directly involving the peritoneum or through other mechanisms such as lymphatic obstruction.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed):
  • Ovarian Torsion or Other Surgical Emergencies: Although less common in men, conditions requiring immediate surgical intervention can sometimes present with ascites and should not be overlooked.
  • Spontaneous Bacterial Peritonitis (SBP) Complicating Cirrhosis: While the provided SAAG and protein levels are not typical for cirrhosis, SBP can occasionally present with atypical fluid characteristics, and missing this diagnosis can be fatal.
• Rare diagnoses:
  • Lymphatic Disorders: Conditions affecting the lymphatic system, such as lymphangiectasia or lymphoma, can lead to chylous ascites or ascites with high protein levels, although these are less common causes.
  • Pancreatic Ascites: Ascites due to pancreatic disease, such as a pancreatic fistula or pancreatitis, can have variable SAAG and protein levels but is an important consideration in the differential diagnosis of ascites with low SAAG and high protein.