Medical Challenge Question 6

A 70 year old African American man comes to the hospital because of new-onset ascites with lower-extremity edema. His symptoms have increased over the past 4 weeks. He has consumes four alcoholic beverages per day for many years. His medical history is notable for coronary artery bypass graft surgery 18 months ago and dyslipidemia. His medications are low-dose aspirin, atorvastatin, and metoprolol.

On physical examination, temperature is 98.7 °F, blood pressure is 124/86 mm Hg, pulse rate is 62/min, and respiration rate is 16/min; BMI is 25. Cardiac examination demonstrates an elevated jugular venous pressure, a normal S1 and S2, and no murmurs. Pulmonary examination findings are normal. Abdominal examination reveals hepatomegaly, distention, dullness to percussion over the flanks, and a positive fluid wave. There is 2+ pitting edema of the lower extremities.

Laboratory studies reveal a serum albumin level of 3.6 g/dL. Other studies, including serum alanine aminotransferase and aspartate aminotransferase levels, are normal.

Paracentesis yields a total nucleated cell count of 220/µL with 20% polymorphonucleocytes. Ascitic fluid albumin level is 2.1 g/dL and total protein is 3.6 g/dL.

Which of the following is the most likely cause of this patient's ascites?

A. Tuberculous peritonitis

B. Constrictive pericarditis

C. Nonalcoholic cirrhosis

D. Alcoholic cirrhosis

E. Malignancy

Reference

Gordon FD. Ascites. Clin Liver Dis. 2012 May;16(2):285-99. PMID: 22541699