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Case history

image A 35-year-old woman underwent a mastectomy for a grade 3 invasive ductal carcinoma of the right breast: T2N0, oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative. She received adjuvant chemotherapy with fluorouracil, epirubicin and cyclophosphamide and 2 years of tamoxifen, which was discontinued early because of side effects.

Five years later she presented with pain in her right leg. A bone scan demonstrated uptake in the right superior pubic ramus. A CT scan showed small-volume lung, liver, bone and subcutaneous metastases. She commenced anastrozole and goserelin acetate, and subsequently underwent a radiation-induced menopause. She received radiotherapy to the right pelvis along with bisphosphonates.

A restaging CT scan 3 years later demonstrated a new 2.3 cm lesion in her liver and increasing prominence of a pulmonary nodule. She stopped anastrozole and commenced exemestane. Six months later she developed a large-volume unilateral pleural effusion. Therapeutic pleural aspiration was performed with good symptomatic benefit. She completed 15 doses of weekly paclitaxel, allowing her to resume cycling, running and swimming. A restaging CT scan 4 months after completing paclitaxel showed that the pulmonary nodule had disappeared, the liver metastases had reduced in size and the right lobe of her liver appeared atrophic. She returned to the clinic 1 month later feeling tired and bloated. She had taken ill-health retirement from work due to increasing symptoms. Clinically there was evidence of ascites. Her blood tests showed raised bilirubin, mild transaminitis and hypoalbuminaemia. She had paracentesis to relieve her symptoms and 10 l of ascitic fluid was drained; human albumin solution was administered concomitantly. Spironolactone was commenced. A further restaging CT demonstrated widespread ascites and a shrunken liver with a nodular appearance. Her cancer appeared stable and low volume.

One month later she deteriorated and died. A postmortem examination revealed a diffusely nodular liver comprised of coarse nodules separated by areas of scarring. It was agreed she died of pseudocirrhosis.

What is the differential diagnosis for ascites?

What is pseudocirrhosis?

How is pseudocirrhosis managed?

What investigations would you consider in a patient with ascites?

What are the management options?

What is the differential diagnosis for ascites?

The most common aetiology of ascites in the general population is cirrhosis (75% of cases). Malignancy is the second most common, accounting for 10% of cases.1 Rarer causes include congestive cardiac failure, tuberculosis, pancreatitis, and low-protein states secondary to conditions such as nephrotic syndrome or protein-losing enteropathy. Malignant ascites is often associated with intrapelvic and intra-abdominal malignancies. A retrospective review found ovarian cancer to be the commonest malignancy causing malignant ascites, followed by gastrointestinal cancers.2

Ascites may be the presenting feature of malignancy and is associated with a poor prognosis; one review reported a median survival rate of 5.7 months.2 In a patient with malignancy it is worthwhile considering other diagnoses as the cause of the presentation with ascites. There is an ever-increasing arsenal of systemic ...

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