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Education in Practice
Recurrent ascites due to constrictive pericarditis
  1. James Philip Howard1,2,
  2. Daniel Jones1,2,
  3. Peter Mills1,
  4. Richard Marley3,
  5. Andrew Wragg1,2
  1. 1NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, UK
  2. 2Department of Cardiology, Barts and the London NHS Trust, London, UK
  3. 3Department of Gastroenterology, Barts and the London NHS Trust, London, UK
  1. Correspondence to Andrew Wragg Department of Cardiology, London Chest Hospital, Bonner Road, Bethnal Green, London E2 9JX, UK; jphoward{at}doctors.org.uk

https://doi.org/10.1136/flgastro-2012-100173

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    Introduction

    Constrictive pericarditis (CP) is a recognised, but unusual cause of chronic ascites.1 ,2 Patients with pericardial constriction may present to non-cardiological specialties,3 ,4 with the symptoms and signs leading to the diagnosis of congestive cardiac failure, lung disease or liver disease.5 ,6 It is important to suspect and rule out CP because with surgery it is treatable and potentially curable. Much of the difficulty in diagnosing CP can be attributed to its insidious course and the absence of typical cardiopulmonary symptoms. Over 50% of patients ending up with pericardiectomy lack symptoms of dyspnoea and orthopnoea.7

    We present two cases, which highlight the potential difficulties in diagnosing CP in patients with chronic ascites. We review the key steps in diagnosis and management, emphasising that raised jugular venous pressure (JVP) is one of the crucial observations in making the diagnosis.

    Case 1

    A 77-year-old man presented with a 2-year history of recurrent ascites requiring serial paracentesis. He had been extensively investigated by both gastroenterological and respiratory physicians. Abdominal ultrasound scans revealed normal appearance of both liver and spleen. Paracentesis demonstrated a high ascitic total protein count of 39, an accompanying high serum-ascites albumin gradient (SAAG) with negative cytology and negative cultures and smears for tuberculosis (TB). Despite this, he received an empirical course of anti-TB therapy. Extensive investigations looking for causes of chronic liver disease were negative. A transthoracic echocardiogram (TTE) revealed normal biventricular function. The left atrium was reported as being dilated but no other abnormalities were detected, therefore a cardiac cause of the ascites was felt unlikely. During an elective admission for paracentesis, an elevated JVP was observed and CP was considered. On review of the echocardiogram, abnormal motion of the intraventricular septum (‘septal bounce’) was observed along with a dilated left atrium and dilated …

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    Footnotes

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.