PakMediNet Discussion Forum : Obstetrics and Gynecology : Clinical Challenge
Clinical Challenge
53 years old female was referred by her family practitioner for evaluation of ascites that she had developed in the past three months. She had also experienced shortness of breath on exertion and lower extremity edema.
A review of the symptoms revealed fatigue, low-grade subjective fevers, intolerance to tight-fitting garments and occasional nausea.
Although she could not account for any changes in her weight, she could no longer fit into any of her pants because of her increasing abdominal girth. A previously obtained ultrasound of the abdomen was remarkable for ascites, without any abnormalities in the liver, gallbladder, spleen or biliary system. She had never had a mammogram or a pap smear.
Her history was unremarkable with no chronic illnesses or surgeries. She was not taking any medication and had no known drug allergies. Alcoholism and drug abuse were negative. She was single and childless and employed by a garden nursery for 30 years.
Her family history was negative.
On examination there were no rashes, telangiectasias or palmer erythema. Normal vital signs. Skin was warm and dry. Pupils were equal, round and reactive. No evidence on icterus. Neck was supple with no evidence on any adenopathy. Lung sounds were clear bilatrally with good air flow. Cardiac exam did not reveal any rub, murmur or gallop. There was brisk capillary refill. Abdominal exam revealed massive ascites with no evidence of caput. No organomegaly could be demonstrated because of massive ascites. Recto-vaginal exam was negative. Hemoccult negative. Had 2+ pitting edema. Neuro negative.
Any thoughts?
[Edited by chameed on 01-28-2005 at 01:58 AM GMT]
[Edited by chameed on 01-28-2005 at 02:01 AM GMT]
Posted by: chameed Posts: 173 :: 28-01-2005 :: | Reply to this Message
Re: Clinical ChallengeCause of this patient's ascites should be investigated. There are number of causes which can cause large ascites which include cirrhosis, tuberculosis, budd chiari syndrome, malignancy, hypo-proteinemia. I would like to know the lab reports of this patient. Is the ascitic fluid exudative or transudative?
Posted by: docosama Posts: 333 :: 28-01-2005 :: | Reply to this Message
Re: Clinical ChallengeA complete blood count, metabolic panel, liver functions, amylase and lipase were within normal range. ANA, Antimitochondrial antibody, alpha-1 antitrypsin, anti smooth muscle antibody, ceruloplasmin, PT, ferritin, iron-binding capacity and hepatitis panel were negative as well. Cytology and AFB culture of the peritoneal fluid were unrevealing. SAAG was <1.1g/dl.
Posted by: chameed Posts: 173 :: 29-01-2005 :: | Reply to this Message
Re: Clinical ChallengeWell, SAAG is suggestive of Exudative Ascites. I would still think of neoplastic process which is causing this ascites. As you are a Gynecologist, I would more think of malignancy of ovaries (meig's?) first. What about CT Abdomen?
Posted by: docosama Posts: 333 :: 29-01-2005 :: | Reply to this Message
Re: Clinical Challenge
interesting case.
A simple practical rule " go where the money is". Laparosopic evaluaton likely to be most productive in this point.
Posted by: drkhawaja Posts: 37 :: 30-01-2005 :: | Reply to this Message
Re: Clinical Challenge
Chest x-ray was significant for elevation of the right hemidiaphragm and the possibility of a small pleural effusion.
CT scans of the abdomen and pelvis demonstrated multiple, small nodular densities throughout the peritoneum, suspicious for malignancy. The ovaries were not visualized on CT scan or on subsequent pelvic ultrasound. The plvic ultrasound did, however, demonstrate a "masslike effect" that was thought to be dilated loops of bowel.
Laparoscopy was out of the question because of massive ascites.
Posted by: chameed Posts: 173 :: 30-01-2005 :: | Reply to this Message
Re: Clinical ChallengeI would like to know the detailed report of Ascitic Fluid R/E. Next, biopsy of the nodular masses is the next step, but the problem is massive ascites. Why dont you drain it first and then go for laparoscopy ??
Posted by: docosama Posts: 333 :: 30-01-2005 :: | Reply to this Message
Re: Clinical Challenge
I ordered an MRI of the abdomen and pelvis for further evaluation.
This revealed two complex masses consistent with ovarian cancer.
Exploratory laparotomy was performed. 8-10 liters of ascitic fluid was removed. She underwent TAH-BSO, omentectomy, pelvic and para-aortic lymph node dissection and debulking of the tumor. Surgical stage III.
Ascitic fluid cytology and pathology of the ovaries revealed serous cyst-adenocarcinoma. Lymph nodes are negative.
Posted by: chameed Posts: 173 :: 30-01-2005 :: | Reply to this Message
Re: Clinical Challenge
Great Work!
Posted by: docosama Posts: 333 :: 31-01-2005 :: | Reply to this Message
Re: Clinical Challenge
Massive ascites is not a contraindication to laparocopy. In fact it makes laparosopy easy. All what has to be done is to remove fluid before creating a pneumoperitoneum. It is now well established that large volumes of fluid can be removed safely as practised during large volume or total paracentesis in patients with cirrhosis.
Thankyou for a good case discussion.
Posted by: drkhawaja Posts: 37 :: 01-02-2005 :: | Reply to this Message
Re: Clinical Challenge
In one of the posts, docosama did mention 'Meigs" and based upon my level of experience, that was my clinical diagnosis from the beginning but I wanted that clinical diagnosis substantiated with one or two additional tests. I, then presented that situation to the patient and her family.
However, these are very difficult and risky procedures and as far I am concerned, patients must know in advance what they are in for.
We can discuss the pros and cons of laparoscopy but in the end, extensive laparotomy is required. Moreover, information to be gained from laparoscopy was available to me from MRI. Also an additional procedure increases the risks from anesthesia etc. I can tell you that drainage of ascitic fluid and creation of pneumo, sounds like a great idea but its not that easy to accomplish on the ground.
Work up was extensive and quick and all the possibilities had to be excluded one by one.
Her prognosis for five year survival is <25%. So far she has refused chemo, and I did not try to push that too much. My experience tells me that chemo has not done much good for the gyn cancer except in cases of chorio.
Her post-op course was uneventful except that she lost a few pounds but her apetite is normal and her GI and genito-urinary systems are working well. We shall see.
Posted by: chameed Posts: 173 :: 01-02-2005 :: | Reply to this Message
Re: Clinical ChallengeGood case discussion. I think palliative care in this case would be more beneficial compared to treatment, because as you mentioned, the prognosis in this case is <25%. I want to know who would you treat massive recurrent ascites?
Posted by: yasir Posts: 90 :: 02-02-2005 :: | Reply to this Message
Re: Clinical ChallengePost-op massive ascites is rare but easy to drain through the cul-de-sac with a large bore needle like Touhy's.
Posted by: chameed Posts: 173 :: 03-02-2005 :: | Reply to this Message