The patient had a work-up for his new onset ascites about 1 week ago and the paracentesis (ascites tap) showed bloody fluid, cultures were negative and the serum-ascites albumin gradient (SAAG) was less than 1.1 g/dL. PPD was negative and the cytology of the ascitic fluid did not show any malignant cells.
A laparoscopy was suggested to look for the cause of his bloody ascites, but due to his extensive
abdominal surgery history, it was decided that an explorative laparotomy would be more appropriate.
The patient had the laparotomy 5 days before this admission. During the procedure, the liver was found to be enlarged, the biopsy showed bridging fibrosis and one liter of bloody ascites was drained. No malignant or any other cause of the bloody ascites was found.
The patient reports no Nausea/Vomiting/Diarrhea/Constipation (N/V/D/C), no headache, no cough, and no sick contacts.
Past medical history (PMH)
Chronic pancreatitis, multiple admissions for abdominal pain over the last 4 years, endoscopic retrograde cholangiopancreatography (ERCP) in 2001 and esophagogastroduodenoscopy (EGD) in 2002 were normal, ESRD on continuous ambulatory peritoneal dialysis (CAPD) for 8 years with multiple bouts of peritonitis, due to this, he was started on HD for the last 1 year, hepatitis C with always normal liver function tests (LFTs) through the years.
Past surgical history (PSH)
Right nephrectomy after a motor vehicle accident (MVA) in 1982, cholecystectomy, ventral hernia repair, arteriovenous (AV) graft for HD.
Medications
Renagel (sevelamer hydrochloride), Colace (docusate), Nephrocaps, ASA, Plavix (clopidogrel), Protonix (pantoprazole), metoprolol, Neurontin (gabapentin) , Benadryl (diphenhydramine).
Social history (SH)
EtOH (alcohol), cocaine and marijuana, denies IV drug use.
Physical examination
WD/WN in NAD
VS 38.7-16-117-126/61
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, diffuse tenderness, no rebound, old surgical scars from R nephrectomy, cholecystectomy, new surgical scars from the laparotomy in the midabdomen, not infected, no rebound, diminished BS, ascites
Ext: no edema, RUE AV graft with positive thrill and bruit
What is the most likely diagnosis?
What laboratory or gabinet workup would you order?
Final diagnosis
What laboratory or gabinet workup would you order?
Final diagnosis
