Ascites Still a Dilemma!

Abstract

Introduction: Ascites is a common finding in clinical practice. It is typically due to liver disease. The etiologic approach of ascites is relatively easy but patients with a mixed picture can sometime complicate the workup. Case Report: Our patient is a 34-year-old previously healthy non-alcoholic Portuguese man who was admitted to Trinitas Hospital on 12/02/2006 complaining of abdominal distension, epigastric pain and significant weight loss. Patient denied any history of illicit drug use, blood transfusion or TB exposure. Physical examination revealed massive ascites with tender abdomen, no jaundice. Preliminary studies included LFTs, INR, amylase, lipase, UA WNL, Hepatitis B, C, HIV, ANA and RF negative. USG and CT abdomen showed massive ascites, normal biliary tree and liver. Paracentesis revealed normal appearing ascitic fluid with SAAG < 1.1, wbc 81(Lymph 90%). Gram stain, culture, AFB culture were negative with normal cytology. MRA showed normal portal vein and 2D Echo was WNL. Stool studies did not show any infection or evidence of malabsorbtion. Peritoneal biopsy was negative for malignancy and tuberculosis. Esophageal, gastric and small bowel biopsies were non-revealing. Patient was treated with multiple paracentesis and empiric antibiotics. Patient improved with resolution of ascites and discharged home. Discussion: Although cirrhosis is the cause of ascites formation in most patients, approximately 15 percent have a cause other than liver disease, including cancer, heart failure, tuberculosis, or nephrotic syndrome. Review of literature revealed that ascites without obvious cause has been associated with dialysis, previous abdominal surgery, hypothyroidism, constrictive pericarditis and mesothelioma. In our case despite extensive workup, it was still a dilemma!