Ascites Albumin Gradient Research Articles

Spontaneous bacterial peritonitis: risk factors and relationship to serum-ascites albumin gradient in chronic liver disease patient

Background: Spontaneous bacterial peritonitis (SBP) is probably the best characterized infectious complication that develops in patients with cirrhosis and ascites. Aims and objective: The present study was done to find the incidence of SBP in patients of chronic liver disease and to find its correlation with serum ascites albumin gradient. Material and Methods: A total of 55 patients were selected for the study and divided into 2 groups; Group A - spontaneous bacterial peritonitis (SBP) and Group B -sterile cirrhotic ascites (SCA). Diagnosis was done by calculating SAAG (Serum Ascites Albumin Gradient) which reflects the differences in osmotic pressure and correlates with portal venous pressure. Total ascitic protein and ascitic -serum total protein ratio were taken as a diagnostic parameter for SBP. Results: Maximum incidence of disease was found between 31-50 years of age. Serum albumin values in SBP (2.50±0.31 gm/dl) when compared with SCA (2.85±0.39) and total ascites albumin in SBP (0.41±0.21) with SCA (0.89±0.31) were significantly different (p 0.05, t=1.17) was found in serum ascites albumin gradient (SAAG), when it was compared between SBP (2.09±0.42 mg/dl) and SCA (1.96±0.37 gm/dl). Conclusion: In a patient of cirrhosis with ascites early diagnosis of development of SBP in a case of SCA can prevent mortality.

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications

BackgroundAscites develops in a subset of patients with pancreatic adenocarcinoma (PAC) at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions. MethodsWe conducted a retrospective analysis of 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and with ascites either at presentation or that developed during the disease course. ResultsFor the 180 patients, the overall survival was 15 months. The time from diagnosis to ascites presentation was 11 months, and the survival time after ascites development was 1.8 months (range, 1.6-2.3 months; 95% confidence interval). Of 62 patients (34%) who had ascitic fluid analyzed, 36 (58%) had positive cytology. Fifty-one (82%) patients had a serum ascites albumin gradient ≥ 1, and 11 (18%) had serum ascites albumin gradient < 1. Sixty-four (36%) patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter; of these, 108 (93%) had a Tenckhoff catheter, 4 (3%) a Pleurx catheter, 4 (3%) a pigtail catheter, and 1 (1%) a Denver catheter. Eight (7%) patients required 2 catheters to be placed, and in 6 (5%), Tenckhoff catheters had to be removed. The main observed complications were spontaneous bacterial peritonitis in 7 (11%) managed with paracenteses versus 26 (23%) who had a catheter placed, catheter malfunction in 8 (7%), and acute renal failure in 6 (3%). After ascites development, 79 (44%) patients received active anti-cancer therapy, and 101 (56%) patients were managed with supportive care alone. ConclusionsIn patients with PAC who presented with or developed ascites, serial paracenteses and indwelling catheters are common methods used for providing symptomatic relief. The complication rate was higher with indwelling catheters, primarily related to infection (eg, bacterial peritonitis). Overall, ascites has a significantly negative prognostic import with a short median survival.

Ascites in Patients on Maintenance Hemodialysis: Causes, Characteristics and Predicting Factors.

To describe the causes, characteristics and factors associated with ascites in patients on maintenance hemodialysis. Observational study. Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, from November 2007 to November 2014. All patients on maintenance hemodialysis and age > 16 years with ascites were included. Frequencies and percentages were computed for different categorical variables. Chi-square or Fischer exact test were used to identify factors associated with ascites like frequency of hemodialysis, serum albumin and cardiac ejection fraction (EF). Odds ratios were calculated for associated factors. Ninety patients were included in this study; 55.5% were males. Median age was 33 years. Cause of ascites was nephrogenic in 77.8%, cardiac failure in 16.7%, hypothyroidism in 6.67%, liver cirrhosis in 4.4%, abdominal tuberculosis in 2.2%, and peritoneal carcinomatosis in 1.1% patients. The ascites was severe in 53.3% patients and severity was associated with serum albumin < 2.8 gm/dL(p=0.007) and cardiac EF < 40% (p=0.028). The ascites was low serum ascites albumin gradient (SAAG), high protein type (LSHP) in 60% patients and associated with hemorrhage (p=0.040). High SAAG, high protein (HSHP) ascites, found in 33.3%, was associated with cardiac EF < 40% (p=0.005) and portal hypertension (p=0.048). High SAAG, low protein (HSLP) ascites, seen in 6.7%, was associated with portal hypertension (p=0.006). The commonest cause of ascites in hemodialysis dependent patients is nephrogenic followed by cardiac failure. Low serum albumin and low cardiac EF predispose to severe forms of ascites.

Clinical profile and comparison of SAAG with ascites fluid total protein (AFTP) in cases of ascites at a tertiary referral hospital in Maharashtra

Aims: This observational prospective study was carried out with aims of 1) study various presentations and clinical features in ascites cases, 2) assess different etiological factors, 3) compare serum ascitic albumin gradient (SAAG) and ascitic fluid total protein (AFTP) in differentiating portal hypertension related causes of ascites from others, 4) study in hospital outcome in cases of ascites . Material and Methods : 100 consecutive ascites cases admitted in wards with clinical diagnosis and sonographic confirmation were recruited in the study. After history and detailed clinical examination cases were subjected to ultrasonography and portal vein Doppler to diagnose portal hypertension which was followed by paracentesis. Serum Albumin & total protein, ascitic fluid albumin and total protein, AFTP and SAAG was determined. Results : Mean age of diagnosis of ascites was 42.41 ±7.72 years and maximum cases in 30-49 years age group. 68% of cases of ascites had cirrhosis of liver, 16% peritoneal (abdominal) tuberculosis, 10% chronic heart failure (CHF), 4% nephrotic syndrome and 2% had ovarian malignancy. Mean AFTP and Mean SAAG was 1.77±0.73gm% and 2.05±0.52 gm% in 78 cases of portal hypertension related ascites respectively. In normal portal pressure cases (n=22) of ascites it was 3.01±0.37 gm% and 0.72±0.19 gm% respectively. Sensitivity of AFTP and SAAG in differentiating portal hypertension related etiology from other causes was 70.51% and 92.31% respectively .Though sensitivity was less, specificity was equal ( 95.45%). Eight cases had variceal bleeding, 9 had hepatorenal syndrome and 15 had hepatic encephalopathy. Total 16 cases of liver cirrhosis with ascites died in hospital commonest cause was hepatic encephalopathy and hepatorenal syndrome.

Correlation between Serum Ascites Albumin Gradient and Esophageal Varices in Patients of Chronic Liver Disease

Correlation between Serum Ascites Albumin Gradient and Esophageal Varices in Patients of Chronic Liver Disease

Presentation, clinical behavior, outcomes and therapies for patients with advanced pancreas adenocarcinoma (PAC) who present with or develop ascites.

209 Background: Ascites develops in a subset of patients with PAC at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions. Methods: We conducted a retrospective analysis of N = 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and ascites either at presentation or which developed during the disease course. Results: For the 180 patients, overall survival was 15 months. Time from diagnosis to ascites presentation was 11 months and survival time after ascites development was 4 months. Of 62 patients (34%) who had ascitic fluid analyzed, N = 36 (58%) had positive cytology, N = 51 (82%) patients had a serum ascites albumin gradient (SAAG) ≥ 1 and N = 11 (18%) had SAAG &lt; 1.1. Sixty-four (36%) of patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter, from these, N = 108 (93%) had a Tenckhoff catheter, N = 4 (3%) Pleurx catheter, N = 3 (2%) Pigtail catheter and one (1%) a Denver catheter. Eight (4%) patients required two catheters to be placed and N = 6 (3%) Tenckhoff catheters had to be removed. Main observed complications: spontaneous bacterial peritonitis in N = 7 (11%) of patients managed with paracenteses vs. N = 34 (19%) who had a catheter placed, catheter malfunction in N = 8 (4%), acute renal failure in N = 6 (3%). After ascites development N = 79 (44%) of patients received active therapy and N = 101 (56%) patients were managed with supportive care alone. Conclusions: In patients with PAC the presence of ascites is a poor prognostic factor. Serial paracenteses and indwelling catheters are common methods used for alleviating patients’ discomfort. The complication rate was higher with indwelling catheters, primarily associated with infections (e.g. bacterial peritonitis) with low rates of complications occurring related to catheter malfunction, acute renal failure or bowel perforation.

Etiological factor of ascites and its correlation with serum ascites albumin gradient and cholesterol gradient in patients admitted at rural area

Background: The etiological spectrum of ascites is vast and practically includes pathology of all the systems. In most cases ascites will appear as a part of a well-recognized illness i.e. cirrhosis, tuberculosis, congestive heart failure, nephrosis or disseminated carcinomatosis. Few patients have more than one cause of ascites formation. Majority of cases of ascites are due to portal hypertension, mainly as a result of cirrhosis. Other subset of cause includes pathology of peritoneum, which are not related to portal hypertension. A portal hypertension ascites was distinguished from the non-portal hypertension causes by determining whether the fluid is transudate or exudate. But many infected and malignancy related samples have been reported to have transudative fluid and many samples obtained from patients with cirrhosis or heart failure had exudative ascitic fluid. Hence there is a need for this study to know the efficacy of serum ascites albumin gradient and serum ascites cholesterol gradient to differentiate ascites of portal and non-portal hypertensive etiology. Ascites associated with portal hypertension has high serum - ascites albumin gradient i.e ≥1.1 gm/dl, whereas ascites associated with peritoneal inflammation or malignancy has low gradient 1.1 gm/dl is suggestive of portal hypertension not only in patients with transudative type of ascites but also in cases with high protein concentration. The Mean±SD of SACG in malignant ascites is 38.2±10.8 and in non-malignant ascites is 78.1±20.2 and is statistically significant in classifying ascites into malignant and non-malignant etiology.

ESTIMATION OF SERUM ASCITIC ALBUMIN GRADIENT (SAAG) AND SERUM ASCITIC CHOLESTEROL GRADIENT (SACG) IN DIFFERENT CAUSES OF ASCITES

Background: The aim of present study was to differentiate the portal hypertension and non-portal hypertension as well as malignant causes of ascites by serum ascites albumin gradient (SAAG) and serum ascites cholesterol gradient(SACG). Material and method: a total of 130 patients having ascites were included in the study. Serum and Ascitic albumin and cholesterol was measured. SAAG and SACG were calculated by subtracting ascitic values from the respective serum values. Results: There was significant difference in SAAG in portal hypertension cases of ascites as compared to non-portal hypertension cases of ascites. In malignant cases the SACG was found significantly lower than non-malignant cases. The efficacy of SAAG in the present study to classify portal hypertension and non-portal hypertension etiology was 98.4%. SACG was able to accurately differentiate the malignant and non-malignant cases in 99.2% of cases at cut off value of 53mg/dl Conclusion: In view of the good diagnostic efficacy, easy availability and cost-effectiveness, serum ascitic albumin and cholesterol gradient is an excellent parameter for the diagnosis of portal hypertension and malignant ascites respectively.

The Evaluation of Serum Ascites Albumin Gradient and Portal Hypertensive changes in Cirrhotic Patients with Ascites.

ABSTRACTIntroductionAscites is a common complication of chronic liver diseases and is related to the extent of portal hypertension. This study evaluated whether the serum ascites albumin gradient (SAAG) (the difference between the albumin level of serum and of ascitic fluid) is endowed with clinical implications.Materials and methodsThis is a prospective study involving 50 patients with cirrhosis of liver with ascites. The SAAG was measured in all patients and its relation with portal hypertensive changes was analyzed.ResultsBased on SAAG values, the patients were divided into three groups: Group 1 – SAAG value 1.1 to 1.49 gm/dL (n = 15); group 2 – SAAG value 1.5 to 1.99 gm/dL (n = 9); and group 3 – SAAG value 2.0 gm/dL (n = 26). In group 1, 14 patients had esophageal varices (93.3%) and 13 had gastropathy (86.6%). In group 2, all 9 patients had esophageal varices (100%), 7 (77.7%) had gastropathy, and 1 (11.1%) had gastric varices. In group 3, all 26 patients had esophageal varices (100%), 24 patients (92.3%) had gastropathy, and 1 patients (3.8%) had gastric varices.Conclusion Serum ascites albumin gradient value is weakly related to the extent of portal hypertension in patients with liver cirrhosis and its implication seems to be limited in clinics.How to cite this articleShahed FHM, Al-Mahtab M, Rahman S. The Evaluation of Serum Ascites Albumin Gradient and Portal Hypertensive changes in Cirrhotic Patients with Ascites. Euroasian J Hepato-Gastroenterol 2016;6(1):8-9.

Delay in Diagnosis of Extra-Pulmonary Tuberculosis by Its Rare Manifestations: A Case Report

Introduction: Tuberculosis is now more frequently observed in older individuals, often with underlying illnesses or conditions that may confuse diagnosis. Rapid diagnosis is mandatory. However, treatment should be initiated immediately based on strong clinical suspicion, because mortality from tuberculosis is most often due to delays in treatment. Case presentation: A 68-year-old male was admitted to our hospital with fever. He had splenomegaly, ascites and right-sided psoas abscess. Chest X-ray was normal. Although the vertebral column was intact, he had asymptomatic sacroiliitis. Bony changes of the right sacroiliac joint seemed to be chronic on computerized tomography (CT) scan. Lack of associated clinical symptoms strengthened this assumption. However, signal alterations of respective areas on magnetic resonance imaging (MRI) suggested active inflammation. Analysis of aspirated pus was positive for acid-fast bacilli and the culture depicted mycobacterial growth. The patient was not cirrhotic yet he had high serum-ascites albumin gradient ascites. He had two hypodense lesions in his liver with a cholestatic pattern in the liver test. He had pancytopenia. Biopsy from his liver and bone marrow showed multiple granulomas. Treatment was started with an anti-tuberculosis regimen of four drugs. He responded well to our therapeutic protocol. Conclusions: Tuberculosis is still a diagnostic challenge, especially when the presentation is atypical and extra-pulmonary.

The diagnostic utility of serum ascites albumin gradient against ascitic fluid total protein for detection of liver disease in patients of ascites- A comparative study

Introduction: Various studies have demonstrated superiority of SAAG (serum ascites albumin gradient) in classifying ascites compared to transudate-exudate concept but with conflicting observations. Ascitic fluid total protein (AFTP) level in ascitic fluid is a much cheaper alternative to the serum ascites albumin gradient ratio. Hence in the study, we have compared the diagnostic accuracy of the old cheaper traditional method against the new method. Methods: Total 102 patients of Ascites were included in the study from J.A. group of hospital, G.R.Medical College (M.P.) in year 2013-15. All medical causes of ascites were included in our study and Non medical causes were excluded. The collected data was analyzed by using Pearson Chi-square statistical analysis to determine correlation between variables. Result: For prediction of liver disease it was found that SAAG was significantly (p value 0.0341) more predictive of Liver disease compared to AFTP. SAAG (p value<0.0009) and AFTP (p value 0.49) were both significant for differentiating cause of ascites when comparison was done between liver and non-liver disease. Conclusion: AFTP is a good surrogate marker for detection of liver disease in ascites. AFTP is an excellent diagnostic test for detection of certain extra hepatic diseases leading to ascites like tubercular peritonitis sub-acute bacterial peritonitis and anaemia-hypo-proteinemia.e

Acute Anemia in a Patient With Hepatocellular Carcinoma

Question: A 64-year-old man presented with syncope. He had been diagnosed with a multifocal hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer stage D 2 months before admission. He denied prodromes, hematemesis, melena, or abdominal pain, and there was no recent history of abdominal trauma. At admission, he was pale and tachycardic, presented with grade 3 ascites (International Ascites Club Classification) and the neurologic examination was unremarkable. Laboratory data revealed de novo normocytic and normochromic anemia (hemoglobin, 4.3 g/dL; normal range, 11.5–18.0) and prothrombin time of 60% (normal, 70%–100%). Upper gastrointestinal endoscopy revealed only small esophageal varices with no stigmata of recent hemorrhage. Paracentesis revealed a bloody fluid with serum–ascites albumin gradient of 1.4 consistent with portal hypertension, 2.4 g/dL of proteins, and 500 cells/mL with predominance of lymphocytes and mesothelial cells, erythrocyte count was not available. Cytology was negative for malignant cells. CT angiography (Figure A) was performed. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome

Ascites, a common occurrence in cirrhotic patients with portal hypertension, is the pathologic accumulation of fluid in the peritoneum. Associated conditions are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP occurs in 30% of patients with ascites and carries a 20% mortality, most often due to the severity of the underlying cirrhosis. HRS involves life-threatening sequela of refractory ascites with limited treatment options; a review that focuses exclusively on this disease can be found elsewhere in this section. The development of these diseases is a poor prognostic feature, and referral for liver transplantation should be a consideration. This review examines ascites, SBP, and HRS and their relation to each other. The primary focus is ascites, addressing its epidemiology, pathophysiology, diagnosis, differential diagnosis, and management. Figures show theories of ascites formation and pathophysiology of HPS. Tables list screening tests on ascitic fluid, serum ascites–albumin gradient, drugs and agents to avoid in patients with ascites, diagnostic criteria for HPS, and clinical features of type 1 HPS. Also included are two recommended, pertinent Web sites for those who wish to learn more about ascites, SBP, and HPS. This review contains 2 highly rendered figures, 5 tables, and 73 references.

64-Year-Old Woman With Diarrhea and Increased Abdominal Girth

64-year-old woman presented to our institution for evaluation of diarrhea and increasing abdominal girth. She had a 1-month history of postprandial diarrhea unrelated to the type of foods she consumed. Her stool was watery, with no evidence of gastrointestinal bleeding. Concurrently, she also noted increasing abdominal girth requiring new pants with a larger waist size. She had no abdominal pain, nausea/vomiting, flushing, light-headedness, or constitutional symptoms. Her medical history was notable for a previous stroke with a mild residual right hand tremor. She was a lifetime nonsmoker, had no history of illicit drug use, and drank alcohol rarely. She had no history of recent travel, infectious exposures, new medications, or herbal supplement intake. Her blood pressure was 136/83 mm Hg, and herheart rate was 98beats/min.Heroxygensaturation was 95% while she breathed room air, and her respiratory rate was 18 breaths/min. Her temperature was 36.9C. Her mental status was normal. Her abdomen was soft, nontender, and mildly distended with hyperactive bowel sounds. Shifting dullness with a fluid wave was present. 1. Which one of the following is the most appropriate diagnostic approach to evaluate the patient’s abdominal symptoms? a. Paracentesis b. Colonoscopy c. Clostridium difficile toxicology screen or polymerase chain reaction d. Serology testing for transglutaminase antibody e. Abdominal radiography

Retraction note: New proposal for the serum ascites albumin gradient cut-off value in Chinese ascitic patients.

Serum ascites albumin gradient (SAAG) has been recognized as a reliable marker in the differential diagnosis of ascites. The etiological background of cirrhosis is rather different between western countries and eastern countries. The threshold of SAAG in Chinese ascitic patients has not been evaluated yet. The aim of this study was to define a new reasonable threshold of SAAG in Chinese ascitic patients. Adult patients with ascites admitted to the Shanghai Changzheng Hospital from Jan 2004 to Jun 2010 were retrospectively analyzed. The diagnostic criteria for cirrhotic ascites are clinical manifestations, radiological features and esophageal-gastric varicosis, or histopathology. Serum was detected by chemical method using a commercial kit. We used receiver operating characteristic (ROC) analysis to achieve maximal sensitivity and specificity of SAAG. The mean value of SAAG in portal-hypertension-related ascites was significantly higher than that in the non-portal-hypertension-related ascites (21.15 ± 4.38 g/L vs 7.48 ± 3.64 g/L, P = 0.002). The SAAG cut-off value under 12.50 g/L predicted portal hypertension ascites with the sensitivity of 99.20%, specificity of 95.10% and accuracy of 97.65%. SAAG is useful to distinguish portal-hypertension-related ascites and non-portal-hypertension-related ascites, and 12.50 g/L might present as a more reasonable threshold in Chinese ascitic patients. The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1602582638991860

Causes, management and complications of ascites: a review

Ascites is the pathological state in which fluid accumulates in the peritoneal cavity. Fluid accumulation may be due to infection and malignancy or due to other diseases like liver disease, heart failure, and renal disease. The ascitic fluid can be graded into Transudative and Exudative fluid based on the serum ascites albumin gradient (SAAG). The prominent cause of ascites is found to be Liver Cirrhosis. The most common symptom of Ascites is recent weight gain, increased abdominal girth and dyspnea. The first line treatment of ascites includes education regarding dietary sodium restriction and oral diuretics. However, other mechanical methods can also be used if the patient is unresponsive to this approach. But, there are some limitations while using these mechanical methods. Ascites is also associated with certain complications like spontaneous bacterial perotinitis, hepatorenal syndrome and dilutional hyponatremia. Ascites itself is not fatal unless it becomes infected. So, early diagnosis and effective treatment should be ensured in order to avoid further complications. This review focuses on the grades, causes, symptoms, management and complications of Ascites.DOI: http://dx.doi.org/10.3329/icpj.v4i3.21936 International Current Pharmaceutical Journal, February 2015, 4(3): 370-377

The Relevance of Ascitic Lactate Dehydrogenase (LDH) and Serum Ascites Albumin Gradient (SAAG) in the Differential Diagnosis of Ascites among Patients in a Nigerian Hospital

The Relevance of Ascitic Lactate Dehydrogenase (LDH) and Serum Ascites Albumin Gradient (SAAG) in the Differential Diagnosis of Ascites among Patients in a Nigerian Hospital

Ascites in the Puerperium in the Context of a Woman with Turner Syndrome Who Conceived through Assisted Reproductive Technology.

The case is about a young female who delivered twins by caesarean section (CS). On the 4th postoperative day, she presented with ascites which was resistant to empirical antibiotic and diuretic treatment. The woman was affected by Turner syndrome (TS); she had a medical background of chronic use of hormonal medication since puberty and conceived through ART- (assisted reproduction techniques-) IVF-oocyte donation. It is important to exhibit high suspicion for clot formation in the hepatic vasculature during the puerperium, especially in the case of history of chronic hormone treatment. Ascites albumin gradient and Doppler values lead to the diagnosis of thrombosis and the administration of high doses of anticoagulants is considered to be fundamental.

A Rare Presentation of Autoimmune Hepatitis Associated With Peripheral Eosinophilia

Introduction: The clinical presentation of autoimmune hepatitis (AIH) is highly variable and provides a significant diagnostic challenge for physicians. We present a rare case of a young female with AIH-associated with peripheral eosinophilia. Case Report: A 24-year-old white female with an intellectual disability presented with a 2-week history of mild fever, new onset ascites, and leg swelling. Two months ago, she had an episode of acute hepatitis A with positive IgG and IgM antibodies. Physical examination revealed ascites, hepatomegaly, and pedal edema. The rest of her exam was unremarkable. Laboratory data showed leukocytosis (12.7) with eosinophilia (64%). Liver function tests were abnormal with bilirubin 1.4 mg/dL, albumin 2.8 g/dL, elevated globulin 4.7 g/dL, ALT 212 U/L, AST 234 U/L, ALP 209 U/L, and INR 1.53. Serum protein electrophoresis showed hypergammaglobulinemia. Stool examination and serology for parasites were negative. Hepatitis A IgG antibody remained reactive while IgM was now equivocal. HBsAg, anti-HCV, and serum acetaminophen were negative. ANA was positive. Total complement was low. CT abdomen showed hepatosplenomegaly, marked ascites, and abdominal wall edema. ECHO was unremarkable. Ascitic fluid analysis revealed a serum ascites albumin gradient of 2.8 and unremarkable cytology. Bone marrow was normocellular with iron deficiency, eosinophilia, and no increase in blasts. Cytogenetics and FISH were normal. Liver biopsy showed chronic hepatitis with moderate periportal infiltrate of small lymphocytes, plasma cells, few eosinophils, and extensive bridging fibrosis. Hence, a diagnosis of AIH was made based on her presentation, hypergammaglobulinemia, positive ANA, low complement, and a liver biopsy compatible with AIH. She was started on steroids, along with diuretics, with improvement in her symptoms. Her liver enzymes continued to improve and her eosinophil count normalized prior to discharge. Discussion: AIH is an inflammatory disease of liver with a female preponderance. The clinical presentation mainly includes features of chronic liver disease. It can, at times, be associated with other extra-hepatic autoimmune disorders and overlap syndromes not seen in our patient. The cause of peripheral eosinophilia in our patient is unclear. Very few cases of AIH associated with peripheral eosinophilia have been reported in literature. Hypereosinophilic syndrome was excluded by the lack of organ involvement. A significant percentage of patients with AIH develop cirrhosis, and 5% develop hepatocellular cancer. Hence, cancer surveillance is important in these patients. Treatment usually includes steroid therapy with or with out the use of other immunosuppressive therapy.