The serum-ascites albumin gradient or gap (SAAG) is a calculation used in medicine to help

determine the cause of ascites.[1] The SAAG may be a better discriminant than the older method
of classifying ascites fluid as a transudate versus exudate.[2]
The formula is as follows:
SAAG = (serum albumin) − (albumin level of ascitic fluid).
Ideally, the two values should be measured at the same time.
This phenomenon is the result of Starling's forces between the fluid of the circulatory system
and ascitic fluid. Under normal circumstances the SAAG is < 1.1 because serum oncotic
pressure (pulling fluid back into circulation) is exactly counterbalanced by the serum
hydrostatic pressure (which pushes fluid out of the circulatory system). This balance is
disturbed in certain diseases (such as the Budd–Chiari syndrome, heart failure, or liver
cirrhosis) that increase the hydrostatic pressure in the circulatory system. The increase in
hydrostatic pressure causes more fluid to leave the circulation into the peritoneal space
(ascites). The SAAG subsequently increases because there is more free fluid leaving the
circulation, concentrating the serum albumin. The albumin does not move across membrane
spaces easily because it is a large molecule. A rare cause of ascites, with elevated SAAG,
and without change in hydrostatic/osmotic pressure is urinary bladder rupture with leakage of
urine into the peritoneal space.

Differential
High gradient
A high gradient (> 1.1 g/dL, >11g/L) indicates the ascites is due to portal hypertension, either
liver related or non-liver related, with approximately 97% accuracy.[2]This is due to
increased hydrostatic pressure within the blood vessels of the hepatic portal system, which in
turn forces water into the peritoneal cavity but leaves proteins such as albumin within the
vasculature.
Important causes of high SAAG ascites (> 1.1 g/dL, >11 g/L) include: cirrhosis of the
liver, heart failure, Budd-Chiari syndrome, portal vein thrombosis, and idiopathic portal
fibrosis.[3]
Low gradient
A low gradient (< 1.1 g/dL, <11 g/L) indicates causes of ascites not associated with
increased portal pressure such as: tuberculosis, pancreatitis, infections, serositis, various
types of peritoneal cancers (peritoneal carcinomatosis) and pulmonary infarcts.

SAAG vs Total ascites protein

SAAG

<1.1 >1.1

<2. Tuberculous Peritonitis, Nephrotic

Cirrhosis, Budd-Chiari (late)
Total 5 syndrome
Protein >2. Cancer, Tuberculosis, Chylous Right HF, Budd-Chiari (early),
5 ascites, Pancreatitis veno-occlusive disease