Medical University of South Carolina Charleston, SC, United States
Michael M. Sutton, DO, Taylor Remillard, MD, Meghan A. Thomas, MD, MS Medical University of South Carolina, Charleston, SC
Introduction: Cryptogenic cirrhosis is a common hospital admission diagnosis. Exploring the true cause for liver dysfunction is crucial for patient care.
Case Description/Methods: 68-year-old male with past medical history of hypertension (HTN), hyperlipidemia (HLD), alcohol use, obesity and recent diagnosis of cryptogenic cirrhosis presents with volume overload. Patient was diagnosed 5 months prior with cryptogenic cirrhosis after presenting with acute encephalopathy, elevated ammonia and imaging consistent with cirrhosis. The etiology of his cirrhosis was considered multifactorial given his persistent alcohol use, HTN, HLD, obesity and family history of nonalcoholic fatty liver disease (NAFLD). He did not undergo liver biopsy and never had previous abdominal ascites requiring diagnostic paracentesis. On admission, physical exam revealed tense ascites and profound scrotal and lower extremity edema. His serum studies were normal outside of a mildly elevated bilirubin (2.8mg/dl), INR (1.45) and BNP (301 pg/ml). Diagnostic paracentesis revealed an elevated serum ascites albumin gradient (SAAG) of 1.2 g/dl and elevated ascitic protein of 3.4 g/dl. The SAAG was consistent with portal hypertension; however, an elevated ascitic protein is unlikely explained by cirrhosis alone. These results led to deeper investigation into patient’s history and revealed he had an episode of pericarditis in his twenties with calcification years following. Transthoracic echocardiogram was pursued and revealed a normal ejection fraction with evidence of thickened, calcified pericardium and physiologic signs concerning for constrictive pericarditis. Cardiac MRI confirmed the diagnosis of constrictive pericarditis. It was determined his “cryptogenic cirrhosis” was a result of congestive hepatopathy from longstanding constrictive pericarditis. Ultimately, the patient underwent successful pericardiectomy with a reduction in right atrial pressure from 33mmHg to 10mmHG intraoperatively.
Discussion: The case demonstrates the importance of keeping cryptogenic cirrhosis as a diagnosis of exclusion. The SAAG and ascitic protein level is critical in the evaluation of new onset cirrhosis with ascites. An elevated SAAG with ascitic protein < 2.5 g/dl is indicative of intrinsic liver disease; whereas, elevated SAAG with ascitic protein level >2.5 g/dl suggests cardiac origin of liver dysfunction. Patients with elevated ascitic protein levels should be considered for further workup including echocardiogram.
Disclosures: Michael Sutton indicated no relevant financial relationships. Taylor Remillard indicated no relevant financial relationships. Meghan Thomas indicated no relevant financial relationships.
Michael M. Sutton, DO, Taylor Remillard, MD, Meghan A. Thomas, MD, MS. P1833 - Cryptogenic? Don't Constrict the Work-Up, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.