markedly distended, non-tender abdomen, with a positive fluid wave and shifting dullness. Laboratory findings revealed body fluid studies with a SAAG ratio less than 1.1 indicating malignancy, but a high hepatic venous pressure gradient pointing to portal hypertension, with multiple cytology findings negative for malignant cells, however with good synthetic liver function. CT abdomen pelvis upon presentation was unremarkable, and consistent with previous imaging findings of known hepatectomy. After repeated paracentesis and multiple courses of antibiotic therapies for SBP, with recurrent ascites, complicated by hyponatremia with no mental status changes, further management of the case involved interventional radiology placing a Denver shunt to control the ascites. After a couple of months, the patient was followed up and found to have progression of disease with cancer seeding into the peritoneum with omental caking. Discussion: We strongly believe the patient's recurrent ascites of unknown origin was most likely a case of recurrent malignancy in ascitic fluid, masquerading as intrahepatic portal hypertension. We hope that this case report highlights that although in the setting of poorly differentiated gallbladder adenocarcinoma with local metastasis and negative margin resections, malignant ascites can occur and must not be mistaken for portal hypertension given the conflicting SAAG ratio and HPVG.
Figure 1. (A) Endoscopic view of large LSG staple line defect that is in open communication with peritoneal cavity with pus, a drainage tube was seen in situ. Note healthy gastric mucosa (B) Total closure of the LSG staple line defect with OverstitchTM endoscopic suturing system (C) Stent fixation with OverstitchTM Endoscopic Suturing System (D) UGI shows no contrast extravasation, and black arrow points at the location of the endoscopic suture placement.
Case Description/Methods: A 57-year-old man with a history of decompensated liver cirrhosis complicated by esophageal varices presented with multiple episodes of hematemesis. He denied diarrhea or bloody stool. As per outside records, his most recent EGD 7 months prior was notable for bleeding esophageal varices requiring 3 band ligations. Patient was tachycardic on presentation. Initial labs showed
Figure 1. A) Endoscopic Images of Transoral Gastric Outlet Revision with APC of the gastrojejunal anastomsis followed by purse string full thickness suturing over a 10 mm CRE balloon. B) EUS image of demonstrating distal phalange deployment of LAMS into the remnant stomach for EUS guided transgastric ERCP. B. Weight chart demonstrating weight loss after RYGB and regain with TORe and LAMS placement.
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