Abstract
Purpose: Ascites secondary to cirrhosis and portal hypertension is typically transudative with a high serum ascites albumin gradient (SAAG > 1.1). Common causes of low SAAG (< 1.1) and high protein (>2) ascites include tuberculosis, malignancy (peritoneal carcinomatosis), pancreatitis, and serositis. We present an unusual case of low SAAG ascites in a patient with portal hypertension. Methods: A clinical vignette case report is presented. Results: A 47-year-old Hispanic male with a history of esophageal reflux and Barrett's esophagus presented with one month of increasing abdominal distention and pain. Physical exam was significant for large ascites and bilateral lower extremity edema. There were no stigmata of liver disease on exam. CT abdomen revealed large ascites, hepatosplenomegaly, and varices. Ultrasound showed heterogenous echogenicity of the liver and patent vessels. Diagnostic paracentesis revealed SAAG of 0.9 and total protein of 4.2. Serum Quantiferon gold was negative, and ascites cytology was negative for malignancy. Serum amylase and lipase were normal. EGD confirmed large esophageal varices and moderate portal hypertensive gastropathy. The patient underwent liver biopsy which demonstrated normal liver parenchyma. Exploratory laparoscopy was performed and revealed nodules along the peritoneal surface and a grossly nodular appearance to the liver consistent with nodular regenerative hyperplasia resulting in his portal hypertension. Omental and peritoneal nodule biopsies were consistent with mesothelioma. Conclusion: Low SAAG ascites is uncommon in the setting of portal hypertension. When found, alternative diagnoses such as malignancy and atypical infections should be considered. In this case report, we describe a patient with portal hypertension from nodular regenerative hyperplasia who had mesothelioma as the explanation for the low SAAG ascites. Exploratory laparoscopy is the gold standard for diagnosis of conditions causing low SAAG ascites.
Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
