A 53-year-old woman comes to the office due to progressive exertional dyspnea over the past several weeks. The patient's abdominal girth has also increased during this time, which has been associated with discomfort and early satiety. Medical history is significant for bacterial endocarditis due to intravenous drug use. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 85/min, and respirations are 18/min. Physical examination shows no jugular venous distension or hepatojugular reflux. Chest is clear to auscultation. The abdomen is distended and nontender. Both shifting dullness and a fluid wave are present. Hepatosplenomegaly is present. There is trace bilateral lower extremity edema. Which of the following best explains this patient's presentation?

Question

A 53-year-old woman comes to the office due to progressive exertional dyspnea over the past several weeks.  The patient's abdominal girth has also increased during this time, which has been associated with discomfort and early satiety.  Medical history is significant for bacterial endocarditis due to intravenous drug use.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 85/min, and respirations are 18/min.  Physical examination shows no jugular venous distension or hepatojugular reflux.  Chest is clear to auscultation.  The abdomen is distended and nontender.  Both shifting dullness and a fluid wave are present.  Hepatosplenomegaly is present.  There is trace bilateral lower extremity edema.  Which of the following best explains this patient's presentation?

Quizplus · Accepted Answer

This patient with progressive dyspnea has ascites (ie, abdominal distension, shifting dullness, fluid wave). Although ascites can occur from a variety of diseases, over 80% of cases are due to cirrhosis. In the United States, cirrhosis is most commonly due to chronic alcohol misuse, nonalcoholic steatohepatitis, and hepatitis C. Given this patient's hepatosplenomegaly and history of intravenous drug use, hepatitis C cirrhosis is the most likely diagnosis. variety of diseases Cirrhosis promotes the formation of ascites due to portal hypertension, which causes hemodynamic change (ie, splanchnic vasodilation) that leads to salt and water retention. Patients with ascites have increased abdominal girth and discomfort, as well as weight gain, dyspnea (from increased abdominal pressure), and early satiety. Physical examination shows shifting dullness and a fluid wave. In the setting of cirrhosis, stigmata of chronic liver disease (eg, spider angiomas, palmar erythema, asterixis, jaundice), hepatomegaly (cirrhotic livers can be small, normal sized, or enlarged), and splenomegaly (typically reflecting congestion from portal hypertension) can also be seen. Laboratory abnormalities in cirrhosis include abnormal liver enzymes, thrombocytopenia, and evidence of synthetic dysfunction, such as hypoalbuminemia (which can cause trace bilateral edema) and elevated international normalized ratio. Abdominal ultrasound can confirm the presence of ascites, and a diagnostic paracentesis should be performed in all patients to confirm the underlying etiology. (Choices B and E) Both constrictive pericarditis and right heart failure can cause ascites, hepatomegaly (due to congestive hepatopathy), and peripheral edema. However, jugular venous distension (JVD) is expected (eg, positive hepatojugular reflex with right heart failure), and Kussmaul sign (ie, rise in JVD with inspiration) may be present. In addition, constrictive pericarditis (which can be idiopathic/viral) usually presents with a pericardial knock (accentuated heart sound before S3, seen in ~50% of cases) and pulsus paradoxus. (Choice C) Nephrotic syndrome often presents with anasarca and ascites due to profound hypoalbuminemia. However, patients typically have massive lower extremity edema (as opposed to this patient's trace edema); in addition, hepatosplenomegaly would be atypical. (Choice D) Metastatic ovarian cancer with peritoneal carcinomatosis can cause malignant ascites. However, because it occurs in advanced cancer, patients usually have abdominal pain (from tumor invasion) and a history of significant weight loss. Splenomegaly is unexpected. Educational objective: Ascites presents with increased abdominal girth and findings of shifting dullness and fluid wave. It is most commonly caused by cirrhosis due to chronic alcohol misuse, nonalcoholic steatohepatitis, or hepatitis C. In the setting of cirrhosis, stigmata of chronic liver disease (eg, spider angiomas, palmar erythema, asterixis, jaundice) and hepatosplenomegaly are also common. References: Nonalcoholic steatohepatitis is the second leading etiology of liver disease among adults awaiting liver transplantation in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/25461851) Ascites: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/19577115) Differential diagnosis of ascites. (http://www.ncbi.nlm.nih.gov/pubmed/9308124)

A 53-Year-Old Woman Comes to the Office Due to Progressive