A Woman With Ascites, Nodular Liver Contour, and Splenomegaly

Abstract

Question: A 66-yearold woman presented with a 6-week history of abdominal distension. History included a modified radical mastectomy and axillary lymph node dissection, radiation, and chemotherapy for breast cancer 8 years earlier. She denied alcohol consumption and had no personal or family history of liver disease. Physical examination revealed a distended abdomen with shifting dullness and a nontender, firm liver edge that extended 3 finger widths below the right costal margin. The only abnormal laboratory values were aspartate aminotransferase, 47 U/L (reference range, 8–43), and alkaline phosphatase at 148 U/L (reference range, 55–142). Computed tomography revealed a slightly irregular liver surface, ascites, and splenomegaly (Figure A). Doppler ultrasonography revealed nodular liver contour with a course inhomogeneous echotexture and decreased antegrade flow in the portal vein without portal or hepatic vein thrombosis. An 18F-FDG–labeled positron emission topography scan did not show increased uptake to suggest FDG-avid malignancy. Ascitic fluid sampling revealed a cloudy white fluid with a nucleated cell count of 248/ L (63% ymphocytes, 27% monocytes, and 1% neutrophils), total protein level of 1.9 g/dL, and triglyceride level of 123 mg/dL. The serum–ascites– lbumin gradient (SAAG) was 2.9 g/dL. Cytology of the peritoneal fluid was negative. A liver biopsy was performed (Figure B). What is the diagnosis? Look on page 871 for the answer and see the GASTROENTEROLOGY website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.