Melvin Lau, MD Series Editor: Richard W. Goodgame, MD


April 09, 2008

Case Presentation

A 42-year-old man complaining of abdominal and lower extremity swelling presented for evaluation.

The patient was previously healthy until 2 months ago when he noticed swelling of his abdomen and both legs. He went to see his primary care physician and was given furosemide. His symptoms initially improved but recurred when his medication ran out 2 weeks prior to admission. He rapidly gained 30 pounds of fluid. The review of systems was otherwise negative. Specifically, there was no history of fever; night sweats; abdominal pain; nausea; vomiting; jaundice; or prior disease of liver, kidneys, heart, or gastrointestinal tract. He had had no prior hospitalizations, operations, or medications (except furosemide, as mentioned). He did not use alcohol, tobacco, health supplements, or illegal substances. He was born and raised in Mexico but moved to the United States 1 year ago. He is a construction worker without known toxic exposures. He is married with 3 children and has had 1 sexual partner. There is no family history of liver disease or cancer.

Physical examination revealed a comfortable man with obvious ascites and lower extremity edema. The vital signs were normal. There was bitemporal wasting and other signs of muscle mass loss. There was no jaundice or scleral icterus. There were no stigmata of chronic liver disease, including spider angiomata, palmar erythema, enlarged parotids, or gynecomastia. Cardiovascular and pulmonary examinations were normal. The abdomen was grossly distended with bulging flanks, a fluid wave, and shifting dullness (Figure 1). There was no tenderness. The liver was palpable 6 cm below the right costal margin. It was firm but not pulsatile. The liver span was 15 cm by percussion. The spleen was not palpable. Pitting edema was present in both legs up to the thighs.

Laboratory studies revealed the following:

  • Hemoglobin: 13.1 g/dL

  • Mean corpuscular volume: 90

  • White blood cell count: 8400 cells/mcL

  • Platelets: 851,000 cells/mcL

  • International normalized ratio: 0.9

  • Total bilirubin: 0.2 mg/dL

  • Alkaline phosphatase: 1804 U/L

  • Gamma glutamyltransferase: 1486 U/L

  • Aspartate aminotransferase: 70 U/dL

  • Alanine aminotransferase: 51 U/L

  • Total protein: 5.3 g/dL

  • Albumin: 0.6 g/dL

  • Urea: 17 mg/dL

  • Creatinine: 1.9 mg/dL

  • 4+ proteinuria by dipstick

  • Urinary protein to creatinine ratio: 21

  • 24-hour urine protein: 17 g

  • Hepatitis serologies: negative

  • Antinuclear antibody and antimitochondrial antibody: negative

  • Erythrocyte sedimentation ratio: 111 mm/min

Diagnostic Question


On the basis of the findings presented above, which of the following is the most likely cause of the patient's liver disease?

  • Chronic hepatitis

  • Extrahepatic biliary obstruction

  • Primary biliary cirrhosis

  • Primary sclerosing cholangitis

  • Infiltrative liver disease

View the correct answer.


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