A 68-year-old man comes to the office due to increased abdominal distension. The patient was discharged from the hospital last week after an acute pulmonary embolism. He also has a history of emphysema caused by extensive tobacco use. The patient has no other medical conditions and does not use alcohol or illicit drugs. Temperature is 37.6 C (99.7 F) , blood pressure is 112/78 mm Hg, pulse is 85/min, and respirations are 18/min. BMI is 27 kg/m². Examination shows increased jugular venous pressure and lower extremity edema. The abdomen is distended, and a fluid wave is present. This patient's ascites most likely developed due to which of the following changes in portal capillary exchange parameters?

Question

Quizplus · Accepted Answer

Ascites can develop in a variety of disease states (eg, cirrhosis, peritoneal metastasis). In this case, the presence of jugular venous distension and lower extremity edema shortly after pulmonary embolism (PE) are highly suggestive of right-sided heart failure (RHF) (ie, cor pulmonale) as the cause of this patient's ascites. Patients with chronic respiratory disorders (eg, emphysema, obstructive sleep apnea) often have baseline pulmonary hypertension due to hypoxia-induced pulmonary vasoconstriction and associated vascular remodelling, which increases the pressure that the right ventricle (RV) must work against to maintain forward flow. These patients are predisposed to RHF, which can develop subacutely from progressive pulmonary hypertension or acutely in the setting of a PE (due to abrupt obstruction of an already compromised pulmonary capillary bed). Ascites due to RHF is associated with the following findings: (Choices A, D, and F) Portal capillary permeability may be increased in the setting of hepatic malignancies due to disruption of portal capillary integrity; however, it is unaffected by RHF. Portal oncotic pressure remains normal early in the disease process. (Choice C) Both increased portal capillary oncotic pressure and decreased portal capillary hydrostatic pressure would help resolve ascites rather than contribute to its formation. Educational objective: Right-sided heart failure promotes the formation of ascites due to increased central venous pressure, which is transmitted to the hepatic sinusoids, leading to increased capillary hydrostatic pressure. Capillary permeability is unaffected. Although chronic passive congestion may eventually result in hepatic synthetic dysfunction (hypoalbuminemia) with low oncotic pressures, the oncotic pressure will remain normal for several weeks at least.

A 68-Year-Old Man Comes to the Office Due to Increased