Clinical Case Report -- A Common Clinical Scenario
For Ascites With An Uncommon Diagnosis

Matt S. Turpin, D.O. and Elise Sottile, M.D.
Matt S. Turpin, D.O. is a third year resident in Internal Medicine at the University of Florida
Health Science Center / Jacksonville. Elise Sottile, M.D. is an associate professor of the
Department of Internal Medicine at the University of Florida Health Science Center / Jacksonville.

A 53 year-old male presented to the emergency room with a history of alcohol and tobacco abuse and three months of ascites. He was seen six weeks earlier by his physician who had begun therapy and diagnostic investigation. After starting diuretic therapy and having a large volume paracentesis, he felt some improvement, but continued to have constipation and decreased appetite. On this occasion, he presented with a reaccumulation of ascites, orthostasis, nausea, vomiting, and abdominal pain.

Prior laboratory data (which included thyroid, hepatic, pancreatic, electrolyte, and hematologic studies) were unremarkable with the exception of the ascitic fluid and an abdominal CT. Peritoneal fluid analysis demonstrated the following: Leukocyte count 496 (Lymphs 90%, Polys 10%), Erythrocytes 3056, glucose 97, Albumin 2.5, Amylase 26, Gram's stain and culture negative. CT-scan of the abdomen revealed peritoneal thickening, associated small bowel thickening, decreased hepato-splenic size and increased density of mesenteric fat (see Figures 1& 2).

The patient had a diagnostic test.

Discussion

The additional diagnostic test was the Serum Albumin to peritoneal fluid Albumin Gradient (SAAG) on a repeat paracentesis upon admission to the hospital. The SAAG was less than 1.1 gm/dl, a "low gradient". Cell count and biochemical analsyes were unchanged from the prior paracentesis.

Since malignancy was becoming a more likely diagnosis, the patient underwent laparoscopic surgery. Biopsies of a pyloric lymph node and the wall of the sigmoid colon contained poorly differentiated adenocarcinoma. No primary tumor was found thus this patient fit the clinical picture of peritoneal carcinomatosis.

A case such as this illustrates the importance of the SAAG in guiding the differential diagnosis of ascites. This patient having a history of alcohol abuse would most likely have a "high gradient" SAAG (i.e., greater than 1.1 gm/dl). The differential diagnosis for high gradient ascities includes cirrhosis, alcoholic hepatitis, cardiac ascites, or massive liver metastasis. Approximately 78% of new onset ascites results from parenchymal liver disease with cirrhosis and alcoholic hepatitis consisting of 69% of the total.¹

However, this patient had ascities with a "low-gradient" SAAG. The most likely diagnoses are peritoneal malignancy and treatable non-malignant diseases such as tuberculosis, pancreatitis, nephrotic syndrome, biliary disease, and serositis of connective tissue disease. In this case, there was no serologic evidence of these non-malignant diseases, and the radiological studies were suggestive, but not pathognomonic, of peritoneal malignancy.

Unfortunately, the diagnosis of peritoneal carcinomatosis brings with it a predicted survival of weeks, except for some forms of ovarian carcinoma. Fluid removal by large volume paracentesis and symptomatic treatments are palliative. Therapies involving intraperitoneal chemotherapy are experimental only. Portal-caval shunting procedures are impractical given the poor pre-operative prognosis and considerable intra- and post-operative risks.²

REFERENCES

1. Broussard CN, Carey CD: Ascites: Diagnosis and Management. Practical Gastroenterology 1998: 16-25.

2. Yamada, ed., et al: Textbook of Gastroenterology, second ed. 1995: 946.

Jacksonville Medicine / July, 1999

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