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Study the usefulness of ascitic fluid cholesterol level in diagnosis of malignant related ascites

Ascites is the pathological accumulation of fluid within abdominal cavity, which can present a challenging diagnostic problem. Malignant ascites accounts for about 10% of all cases of ascites and is usually caused by ovarian, endometrial, lung, breast, colorectal, pancreatic, hepatobiliary, and primary peritoneal carcinomas. The differentiation between malignancy-related ascites (MRA) and non-malignant ascites (NMA) is important for further diagnostic and therapeutic procedures.

Papers about the detection of ascitic cholesterol have been published a lot and they have shown a relatively high diagnostic efficiency in differential diagnosis of MRA. 2,3 However, conflicting results have been reported and the exact role of ascitic fluid cholesterol concentration remains unclear. Therefore, author performed this study to establish the usefulness of ascitic fluid cholesterol level in diagnosis of malignant related ascites.
Aims and objectives of this study was to study the usefulness of ascitic fluid cholesterol level in diagnosis of malignant Related ascites. Those patients who are already on treatment of chemotherapy and or radiotherapy.

Statistical analysis
The data was processed in MS Excel and analysis was carried out using SPSS (23 th version). Quantitative variables were analyzed using mean and SD. The results were statistically analyzed by Student 't' test. Two tailed probability values of <0.05 was taken as indicating significance.

RESULTS
In this study, author included 80 patients of ascites. Among these 80 patients, 74 were included in the study and 6 excluded because the ascitic fluid analysis was suggestive of bacterial peritonitis. The patients were divided into two groups malignant(n=20) and nonmalignant(n=54). The non-malignant group was further subdivided into two groups tubercular (n=7) and nontubercular cases(n=47).  For the non-malignant group mean value of ascitic fluid cholesterol (mg/dl) is 6.7+2.5 vs 100.85+34.28 in malignant group. The student t-test is applied, p value is <0.01 indicating that ascitic cholesterol is significantly higher in malignant group (Table 2).  For the non-tubercular group mean value of ascitic fluid cholesterol (mg/dl) is 6.7+2.5 vs 32.43+15.7 in tubercular group. The student t-test is applied, p value is <0.01 indicating that ascitic cholesterol is significantly higher in malignant group (Table 4).

DISCUSSION
One of the most common challenges in the treatment of ascites patients is to reveal the cause of the disease as rapidly as possible for an appropriate management. Ascitic fluid can accumulate as an exudate or a transudate, that play a pivotal role in the diagnosis and management of ascites.
The search for novel biochemical markers in the serum and/or ascitic fluid is still under investigation. In this approach, cholesterol have shown to be promising marker.
In this study, author included 80 patients of ascites. Among these 80 patients, 74 were included in the study and 6 excluded because the ascitic fluid analysis was suggestive of bacterial peritonitis. The patients were divided into two groups malignant(n=20) and nonmalignant(n=54). The non-malignant group was further subdivided into two groups tubercular (n=7) and nontubercular cases(n=47).
The ascitic fluid cholesterol was compared in malignant and non-malignant (excluding tubercular cases) group. The mean cholesterol level was found to be 100.85mg/dl in malignant group and 6.7mg/dl in non-malignant group with a P-value of <0.01. With a cut off value of ascitic fluid cholesterol 100mg/dl, the specificity was 100% and sensitivity 65%. Rana SV et al also reported that the mean ascitic cholesterol level was significantly higher in malignant ascites than in non-malignant ascites, with a cut off level of 70mg/dl for ascitic fluid cholesterol. 10 The specificity (100%) and diagnostic efficiency (94%) of ascitic fluid cholesterol is better than the 84% specificity and 86% diagnostic efficiency of serum ascitic albumin gradient. The specificity is found to be similar as Rana SV et al and sensitivity is lower than their study because the cut off value of ascitic fluid cholesterol used in this study was higher (100mg/dl vs 70mg/dl). 10 Almost similar result also reported by Sastry AS et al, the ascitic fluid cholesterol was found higher in malignant ascites (1288.10) vs 51.408.3 in non-malignant cases. 11 The ascitic fluid cholesterol has sensitivity 88% vs 65% in this study, specificity is 96% vs 100% in this study.
Almost similar result was also reported by Bijoor AR et al studied the ascitic fluid and serum concentration of total cholesterol, total proteins and albumin in a group of 45 patients. 12  In this study author also compared the ascitic fluid cholesterol (mg/dl) between malignant (n=20) and tubercular group of ascites(n=7 In this study author also compared the ascitic fluid cholesterol(mg/dl) between rest of non-malignant (n=47) and tubercular group of ascites (n=7). The mean level of ascitic fluid cholesterol found in rest of non-malignant group was 6.7 vs 32.43 tubercular group which is statistically significant (p<0.01). This finding needs further studies.

CONCLUSION
Out of 80 patients, 74 patients were included in the study and 6 patients were excluded due to bacterial peritonitis. The lowest age was 20 years and highest was 85 years. The mean age of patients was 45.81+12.52 years. Out of 74 patients 43(58%) were males and 31(42%) were females.
The mean value of ascitic fluid cholesterol in malignant group was 100.85+34.28 vs 6.7+2.5 in non-malignant group (p value <0.01). Ascitic fluid cholesterol is highly specific (100%) and sensitive (65%) at cut off value of 100mg/dl in differentiating benign and malignant cause of ascites. The mean value of ascitic fluid cholesterol in malignant group was 100.80+34.28 vs 32.43+15.7 in tubercular group.
Ascitic fluid cholesterol having high specificity, can be used for differentiating between non-malignant and malignant ascites. It can also be used to differentiate tubercular ascites from malignant ascites. Hence this parameter is being simple and cost effective can be widely used to differentiate non-malignant and malignant ascites, even in small centers with limited diagnostic facilities.