The Right Angle

A CLINICAL PROBLEM-SOLVING article by Michael Reed,from University of Michigan Medical School, Ann Arbor.
A 25-year-old man presented to an ER with abdominal distention and discomfort. He had noticed his increased girth a year earlier and attributed it to beer, but it progressed after he cut back. His distention was associated with early satiety, fatigue, and exertional dyspnea.
The patient reported a history of pneumonia after spending spring break in Florida 2 years previously, and he was told at that time that he had “fluid” around his lung and heart.
On physical examination, the patient appeared to be in mild discomfort. There was no evidence of a jugular venous pulse with the head of the bed elevated to 30 degrees. His chest was clear on auscultation, and the heart sounds were regular, with no murmur, rub, or gallop. His abdomen was tense, with shifting dullness and mild, diffuse tenderness.
An electrocardiogram showed sinus rhythm with right atrial enlargement. An ultrasonographic examination of the abdomen showed marked ascites with splenomegaly and a mild increase in liver echodensity. CT of the abdomen and pelvis showed massive ascites and splenomegaly. Laboratory testing for various causes of chronic liver disease was unrevealing. Paracentesis was performed, and 3.5 liters of clear yellow fluid were aspirated.
This case illustrates an unusual cause of ascites in a young man.