Bloody Ascites and Gas Under the Diaphragm

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D

A 39-year-old African American male (AAM) with a history of new onset ascites 1 week ago, cirrhosis, and end stage renal disease on hemodialysis (ESRD on HD) is admitted to the hospital from the HD unit after he was found to have fever of 39 C. He has no complaints apart from a chronic abdominal pain for 4 years which was attributed to chronic pancreatitis. He has an extensive past medical history (PMH), which is described in the PMH section below.

The patient had a work-up for his new onset ascites about 1 week ago and the paracentesis (ascites tap) showed bloody fluid, cultures were negative and the serum-ascites albumin gradient (SAAG) was less than 1.1 g/dL. PPD was negative and the cytology of the ascitic fluid did not show any malignant cells.

A laparoscopy was suggested to look for the cause of his bloody ascites, but due to his extensive
abdominal surgery history, it was decided that an explorative laparotomy would be more appropriate.

The patient had the laparotomy 5 days before this admission. During the procedure, the liver was found to be enlarged, the biopsy showed bridging fibrosis and one liter of bloody ascites was drained. No malignant or any other cause of the bloody ascites was found.

The patient reports no Nausea/Vomiting/Diarrhea/Constipation (N/V/D/C), no headache, no cough, and no sick contacts.

Past medical history (PMH)

Chronic pancreatitis, multiple admissions for abdominal pain over the last 4 years, endoscopic retrograde cholangiopancreatography (ERCP) in 2001 and esophagogastroduodenoscopy (EGD) in 2002 were normal, ESRD on continuous ambulatory peritoneal dialysis (CAPD) for 8 years with multiple bouts of peritonitis, due to this, he was started on HD for the last 1 year, hepatitis C with always normal liver function tests (LFTs) through the years.

Past surgical history (PSH)

Right nephrectomy after a motor vehicle accident (MVA) in 1982, cholecystectomy, ventral hernia repair, arteriovenous (AV) graft for HD.


Renagel (sevelamer hydrochloride), Colace (docusate), Nephrocaps, ASA, Plavix (clopidogrel), Protonix (pantoprazole), metoprolol, Neurontin (gabapentin) , Benadryl (diphenhydramine).

Social history (SH)

EtOH (alcohol), cocaine and marijuana, denies IV drug use.

Physical examination

VS 38.7-16-117-126/61
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, diffuse tenderness, no rebound, old surgical scars from R nephrectomy, cholecystectomy, new surgical scars from the laparotomy in the midabdomen, not infected, no rebound, diminished BS, ascites
Ext: no edema, RUE AV graft with positive thrill and bruit

What is the most likely diagnosis?

Peritonitis after surgery?
Abdominal abscess?
C. diff. colitis?
HD related sepsis?

What laboratory workup would you order?

CT of the abdomen?

Would you do a paracentesis ("tap") of the ascites?

He had an ultrasound (U/S) guided paracentesis during which 700 cc of bloody fluid were drained and sent to the lab.

Paracentesis report (click to enlarge the image).

What happened?

BMP; paracentesis labwork, PMN more than 250 (around 500) (click to enlarge the image).

A previous CXR from 5 days ago (left); the new CXR (middle); air/fluid level close-up (right) (click to enlarge the images).

A lateral CXR from 5 days ago (left), the new CXR showing an air/fluid level (middle); CXR report (right) (click to enlarge the images).

The patient was started on ciprofloxacin and given one dose of vancomycin (Vanco) (1 gm IV x 1).

The CXR showed gas under the diaphragm which can be normal after a laparotomy (also after a laparoscopy or even a PEG tube placement).

How do we use serum-ascites albumin gradient (SAAG)?

SAAG higher than 1.1 g/dL may indicate ascites due to portal hypertension (high SAAG = high pressure).

If SAAG is less than 1.1 g/dL, the reason may be peritonitis, TB or malignancy.

Our patient's SAAG (calculated from the labwork above) is 0.8 g/dL.

The PPD was negative and the cytology showed inflammatory cells but no malignant cells. Blood cultures (BCx) grew Gram-positive cocci (GPC), latex/coagulase negative but only 1 of 4 - it was most likely a contaminant. An Infectious Disease (ID) consult was called.

The patient's condition improved and his fever subsided. A CT scan of the abdomen and a WBC scan did not show any source of infection.

Final diagnosis

Spontaneous bacterial peritonitis (SBP).

What did we learn from this case?

How to order relevant labwork for ascites work-up.

Not all gas under the diaphragm is due to a perforated viscus.


Ascites. Rahil Shah, MD, Janice M Fields, MD, FACG. eMedicine.
Management of adult patients with ascites due to cirrhosis. National Guideline Clearinghouse.
Management of Cirrhosis and Ascites. Pere Ginès, M.D., Andrés Cárdenas, M.D., Vicente Arroyo, M.D., and Juan Rodés, M.D. NEJM, Volume 350:1646-1654 April 15, 2004 Number 16.
Exam of the Abdomen - A Practical Guide to Clinical Medicine. University of California (UCSD).
Cirrhosis - JAMA Patient Page, 2012.

Published: 03/01/2004
Updated: 01/07/2008


  1. please would some one corret this it is full with abbreviations that are not clear. all you have to do is post in your blog the meaning of this abbreviations and problem solve.

  2. What does the "(B)" mean?

  3. "(B)" = bilateral

  4. can u know me other causes of gas under diaphragm other than viscus perforation?

  5. "causes of gas under diaphragm other than viscus perforation?"

    - recent surgery
    - sexual intercourse