The patient had numerous bouts of ascites, but this time the fluid’s color and composition heralded a new and ominous diagnosis. A 75-year-old woman with cirrhosis secondary to nonalcoholic steatohepatitis was admitted with abdominal pain. Her medical history also included coronary artery bypass grafting, congestive heart failure with a reduced ejection fraction of 40%, chronic kidney disease (stage III), type 2 diabetes, and obesity.
Her cirrhosis had been decompensated in the past by paraesophageal varices and refractory ascites. Therapeutic paracentesis was frequently required. One year earlier, the patient’s ascites test results demonstrated an elevated serum-ascites albumin gradient of 2.4 g/dL and a borderline total protein level of 2.3 g/dL. At that time, ascites was attributed to portal hypertension from cirrhosis, with a potential contribution from heart failure.
Assessment
A physical examination revealed a chronically ill, obese (body mass index, 37 kg/m2), elderly woman in no acute distress. She had rales in the right lung base and a distended abdomen with normoactive bowel sounds. Mild tenderness to abdominal palpation and a positive fluid wave were also noted. In addition, she had 1+ pitting edema of the bilateral lower extremities.
The patient’s laboratory testing revealed the following levels: serum sodium, 135 mEq/L; creatinine, 1.26 mg/dL (glomerular filtration rate, 41 mL/min); aspartate aminotransferase, 33 U/L; alanine aminotransferase, 9 U/L; alkaline phosphatase, 128 U/L; direct bilirubin, 0.3 mg/dL; total bilirubin, 0.7 mg/dL; albumin, 3.2 g/dL; and total protein, 6 g/dL. She had an international normalized ratio of 1.1 and a calculated model of end-stage liver disease (MELD-Na) score of 13. Her complete blood count showed a hemoglobin level of 11.3 g/dL, a platelet count of 180 × 103 platelets/µL, and a white blood cell count of 8800 cells/µL with 75% neutrophils, 12% lymphocytes, 12% monocytes, 0% eosinophils, and 0% basophils. A point-of-care ultrasound revealed moderate abdominal ascites.
Ultrasound-guided therapeutic paracentesis yielded 3 L of cloudy, amber fluid concerning for possible chylous ascites1 (Figure 1). The patient experienced immediate relief of her abdominal pain. Laboratory studies of the ascitic fluid measured albumin at 1 g/dL (serum ascites albumin gradient, >1.1 g/dL), red blood cells at 8000 cells/µL, and white blood cells at 483 cells/µL, of which 5% were segmented neutrophils, 90% were lymphocytes, and 5% were monocytes. A Gram stain and bacterial culture of the ascitic fluid were negative. The fluid’s appearance warranted a triglyceride level, which was elevated at 375 mg/dL.
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-Vipul Nayi, MD, MS, Yanhua Wang, MD, PhD, Benjamin Galen, MD
This article originally appeared in the November issue of The American Journal of Medicine.
