An encompassing issue

Abstract

A thorough history to guide further work-up should include bowel habits, stool character, a detailed description of any abdominal pain, and the presence of associated fevers, chills, night sweats, or weight changes. He reported several weeks of early satiety and postprandial vomiting with 40 pounds of unintentional weight loss. He noted the recent onset of urinary urgency and straining to pass bowel movements. He denied fevers, chills, night sweats, hematochezia, and melena. A work-up had been initiated at a different clinic 1 month prior. Abdominal computed tomogram (CT) had shown large volume ascites, a small left pleural effusion, mesenteric fat stranding, omental nodularity, and a normal appearing liver. Abdominal ultrasound with doppler had shown a patent portal venous system and hepatic vein. Platelet count, albumin, and international normalized ratio (INR) were normal. Alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA-19) were normal. The tuberculosis interferon-gamma release assay (IGRA) was negative. Hepatitis viral serologies were nonreactive. He had been started on diuretics and had three serial paracenteses with the removal of 1.5, 3.75, and 4 L of ascites. Ascitic fluid was hazy and yellow, and there were 779 nucleated cells/mm 3 (97% lymphocytes). Ascitic bacterial cultures were negative. The serum-ascites albumin gradient (SAAG) was 1.4 g/dl.Cytology showed mature lymphocytes.