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Case records of the Massachusetts General Hospital. Case 15-2006. A 46-year-old woman with sudden onset of abdominal distention.

Dr. Patrick S. Yachimski (Gastrointestinal Unit): A 46-year-old woman was admitted to this hospital because of rapidly increasing abdominal girth. She had been well until five weeks earlier, when increasing abdominal distention developed over a period of several days and was accompanied by a rapid increase in weight (from a baseline of 56.7 kg to 70.3 kg), right upper abdominal discomfort, nausea, and vomiting. She saw her primary care physician, who referred her to a gastroenterologist. Abdominal paracentesis was performed, and 3.3 liters of ascitic fluid was removed. The serum–ascites albumin gradient was reported to be 1.2 g per deciliter. The patient was given prescriptions for furosemide and spironolactone. Three days later, the ascites had reaccumulated, the patient’s temperature rose to 38.1°C, and she was admitted to another hospital. Repeated paracentesis showed no evidence of spontaneous bacterial peritonitis. The results of laboratory tests are shown in Table 1. On the fifth hospital day, an abdominal Doppler ultrasonography was reported to show ascites, hepatofugal flow in the right portal vein, hepatopedal flow in the left portal and splenic veins, and a recanalized umbilical vein. The left and right hepatic veins were not visualized. A liver biopsy was performed; microscopical examination of the biopsy specimen showed evidence of venous outflow obstruction, with changes suggestive of partial or incomplete cirrhosis. An abdominal computed tomography (CT) performed on the eighth hospital day disclosed a narrow intrahepatic inferior vena cava. Also on the eighth day, pain and swelling developed in the right leg. Ultrasonography disclosed deep venous thrombosis involving the right common femoral vein, superficial femoral vein, deep femoral vein, and popliteal vein. Heparin therapy was begun. The results of hypercoagulability testing, performed after the initiation of anticoagulation therapy, are shown in Table 1. The anticoagulation medication was gradually changed to warfarin, and the patient was discharged home on the 18th hospital day, with a referral for outpatient evaluation by a hepatologist. Her weight at discharge was 60.8 kg. Three days after discharge, the patient came to the emergency department of this hospital because of increasing abdominal girth, despite continued diuretic therapy. Case 15-2006: A 46-Year-Old Woman with Sudden Onset of Abdominal Distention