The Clinical Problem Solvers Episode 114: RLR #15 – Ascites (patient) and Tears (RR)
Episode description
Reza and Rabih tackle a case of Ascites.
More about the RLR series here.
Episode Summary
An elderly woman with a history of progressive weakness, falls, and recently diagnosed ascites presented with weight loss and functional decline. Her workup was notable for ascites with a low serum-ascites albumin gradient (SAAG), thrombocytosis, and imaging evidence of peritoneal enhancement with omental nodularity and multiple pancreatic lesions. Biopsies of the peritoneal nodules were initially unrevealing for infections or solid malignancies. Ultimately, further tissue examination revealed primary peritoneal mesothelioma. The patient was not started on treatment and passed away one month later.
Teaching Points
The most common causes of low SAAG ascites include malignancy and infection. Malignancy can cause low SAAG ascites via peritoneal carcinomatosis (seen most commonly ovarian, bladder, or gastric cancer) as well as peritoneal mesothelioma. Tuberculosis is an important and difficult to diagnose infectious cause of low SAAG ascites. Ascitic fluid often reveals a lymphocytic predominance with elevated protein. Additionally, an elevated ascitic adenosine deaminase level (ADA) can suggest peritoneal tuberculosis
Asbestos exposure can lead to an array of benign and malignant diseases. Manifestations within the pulmonary parenchyma include asbestosis (a form of diffuse pulmonary fibrosis resulting in interstitial lung disease) and lung cancer (both small cell and non-small cell lung cancers). Pleural complications of asbestos exposure can include pleural effusions, pleural plaques, and malignant mesothelioma. Rarely, asbestos-related complications can occur in extra-pulmonary sites and present as peritoneal mesothelioma, with diffuse peritoneal nodules and low-SAAG ascites.