A 52-year-old woman is hospitalized because of shortness of breath on exertion, abdominal distention, and a 25-pound weight loss in the past three months. The symptoms have been progressively getting worse over the past four weeks. Her other medical problems include chronic obstructive pulmonary disease, coronary artery disease, cholelithiasis, and hepatitis-C. She has smoked two packs of cigarettes daily for 30 years. She has drunk four to six 12-ounce beers daily for 20 years. Her mother has a history of breast cancer. Her vital signs are within normal limits. Physical examination is unremarkable except for the presence of massive ascites on abdominal examination. Diagnostic paracentesis and serum chemistries reveal: Which of the following is the most likely cause of the ascites?

Question

A 52-year-old woman is hospitalized because of shortness of breath on exertion, abdominal distention, and a 25-pound weight loss in the past three months.  The symptoms have been progressively getting worse over the past four weeks.  Her other medical problems include chronic obstructive pulmonary disease, coronary artery disease, cholelithiasis, and hepatitis-C.  She has smoked two packs of cigarettes daily for 30 years.  She has drunk four to six 12-ounce beers daily for >20 years.  Her mother has a history of breast cancer.  Her vital signs are within normal limits.  Physical examination is unremarkable except for the presence of massive ascites on abdominal examination.  Diagnostic paracentesis and serum chemistries reveal:  Which of the following is the most likely cause of the ascites?

Quizplus · Accepted Answer

Explanation: Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis. The differential diagnosis of ascites can be narrowed down by calculating the serum-ascites albumin gradient (SAAG), which is equal to the serum albumin value minus the ascitic fluid albumin value (not the ratio of the two). The SAAG value is useful in identifying the presence or absence of portal hypertension and has replaced the old transudative-exudative model of classifying ascitic fluid. A SAAG value >1.1 g/dL is known as high albumin-gradient ascitic fluid and indicates portal hypertension, while a value < 1.1 g/dL is known as low albumin-gradient ascitic fluid and indicates that the patient does not have portal hypertension. Clinical conditions associated with high SAAG (>1.1 g/dL) include congestive heart failure (Choice B), cirrhosis (Choice C), and alcoholic hepatitis (Choice E). Conditions associated with low (< 1.1 g/dL) albumin gradient include peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis. This patient has a SAAG of 0.6 g/dL (2.8 minus 2.2), which indicates nonportal hypertensive etiology of her ascites. Given her clinical presentation, carcinomatosis from malignancy, such as ovarian cancer, would be a likely etiology. She should have further investigation to confirm the diagnosis. (Choice D) Budd-Chiari syndrome is one of the postsinusoidal noncirrhotic causes of portal hypertension and is caused by thrombosis of the hepatic veins and/or suprahepatic inferior vena cava. The SAAG value in patients with Budd-Chiari syndrome is >1.1 g/dL. Educational objective: A serum-ascites albumin gradient value of >1.1 g/dL indicates the presence of portal hypertension, while a value of <1.1 g/dL indicates the absence of portal hypertension. References: The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites (http://www.ncbi.nlm.nih.gov/pubmed/1616215)

A 52-Year-Old Woman Is Hospitalized Because of Shortness of Breath