Konstantinos Lontos, MD, and Xiaoning Yuan, MD, PhD
December 2, 2016
A 48-year-old man presented with abdominal distention 6 weeks after splenectomy. He had a history of hypertension, gastroesophageal reflux disease, and gastroesophageal varices complicated by recurrent gastrointestinal hemorrhage, found to be secondary to splenic vein thrombosis (See Image 1A). He underwent splenectomy at an outside hospital as first line treatment for splenic vein thrombosis, and his initial post-operative course was uncomplicated. Three weeks after the surgery, the patient presented to an outside hospital for new abdominal distention thought to be secondary to decompensated cirrhosis. His symptoms initially improved after paracentesis. The ascitic fluid was described as yellow and cloudy, with studies demonstrating WBC 281×103 cells/mL (39% PMNs, 45% macrophages), RBC 605×106 cells/mL, total protein 3 g/dL, fluid LDH 68 U/L, cytology negative for malignant cells, culture negative. He subsequently underwent weekly therapeutic paracentesis for the next 3 weeks. CT imaging was negative for post-splenectomy portal vein thrombosis (See Image 1B) and splenic biopsy specimens were found to be negative for malignancy.
The patient was transferred to our institution 6 weeks post-operation for further evaluation of his ascites. On presentation, he admitted to constipation, weight loss and shortness of breath. On exam, he was normotensive at 105/70 mmHg with positive orthostatic vitals, tachycardic to 111 bpm and afebrile at 36.4o C. His mentation was intact without asterixis. He had significant abdominal distention with shifting dullness and a fluid wave, but no stigmata of end stage liver disease. His extremities were warm but with decreased capillary refill. The rest of his physical exam was normal.
His labs were significant for Hgb 12.9 mg/dL, WBC 19.9×103 cells/mL, platelets 621×103/mL, INR 1.1, Cr 1.11 mg/dL, Na 124 mmol/L and urine Na 80 mmol/L.
His diuretics were discontinued, and he was given a fluid challenge. A diagnostic paracentesis was performed (See Image 2), and empiric antibiotics were started.
Click here to view answer
References:
1. Weniger M, D’Haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment options for chylous ascites after major abdominal surgery: a systematic review. Am J Surg. 2015.
2. Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin analogues for pancreatic surgery. Cochrane database Syst Rev. 2013;4:CD008370.
Authors:
1. Konstantinos Lontos, M.D. is an Internal Medicine Resident at the University of Pittsburgh Medical Center in Pittsburgh, PA.
2. Xiaoning Yuan, M.D., Ph.D. is an Internal Medicine Resident at the University of Pittsburgh Medical Center in Pittsburgh, PA.