The $64,000 question

Abstract

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. A 40-year-old Sudanese man was admitted due to worsening abdominal pain with recurrent ascites. He had a history of hepatitis B (HBV) infection and diabetes. He previously drank 3 beers per day on the weekends, but he had not consumed alcohol in over a year. He was born in Sudan but lived in Egypt most of his adult life; he immigrated to the United States 6 years previously. He was hospitalized out of state 9 months ago for "a swollen abdomen" and underwent an exploratory laparotomy that reportedly was unremarkable except for ascites.Portal hypertension due to liver disease is the most common cause of ascites. This patient has a known risk factor for liver disease (history of HBV infection). Although his reported alcohol consumption is low, there is a synergistic effect on liver injury in the setting of chronic hepatitis. Abdominal pain in the setting of ascites needs to be urgently evaluated to exclude spontaneous bacterial peritonitis (SBP). Also, because chronic HBV infection is the major risk factor for hepatocellular carcinoma in the world, malignant ascites is in the differential. Hepatic vascular thrombosis and tuberculous peritonitis (given the patient's country of origin and travel history) also should be considered. The most appropriate initial test would be a diagnostic paracentesis to support or exclude the presence of SBP and direct the evaluation toward liver disease or other less-common causes of ascites.The patient was seen as an outpatient 5 months prior to admission with transient fever and joint pains. Laboratory studies at that visit were notable for a serum albumin of 3.2 g/dL (normal 3.5-5), 2.4 g of predicted 24-hour protein on urinalysis (normal <30 mg per 24 hours), creatinine of 0.5 mg/dL (normal 0.8-1.3), and a positive hepatitis B surface antibody. The working diagnosis was a nonspecific viral syndrome and his symptoms resolved without treatment. One month later, he developed ascites and mild lower extremity edema. Additional laboratory studies at that time showed a normocytic anemia with hemoglobin 11.7 g/dL (normal 13.5-17.5) and leukopenia with white blood cell count of 2.4 3 10 9 /L (normal 3.5-10.5), neutrophil count of 1.45 3 10 9 /L (normal 1.7-7.0), and lymphocyte count of 0.58 3 10 9 /L (normal 0.90-2.90). Transaminases, serum bilirubin, prothrombin time, alpha fetoprotein, and peripheral blood smear were normal. Human immunodeficiency virus antibody screen and QuantiFERON-TB assay were negative. Hemoglobin A1c was 6.2% (normal 4.0-6.0). Repeat urinalysis demonstrated 883 mg of predicted 24-hour protein. Computed tomography (CT) of the abdomen showed a large amount of intra-abdominal ...