A 56-year-old Patient with Recurrent Refractory Ascites and Abdominal Pain

Aim: to demonstrate the differential diagnosis of recurrent ascites in a patient without chronic liver disease.

Key points. The patient came to the clinic with complaints of an increase in the volume of the abdomen, shortness of breath during moderate physical activity, weight loss, and severe general weakness. The increase in the volume of the abdomen, accompanied by pain, had been occurring periodically for 12 years without any obvious cause. This condition was assessed as a manifestation of portal hypertension. Laboratory signs of systemic inflammation were noted, while liver function remained intact. Laparoscopy and therapeutic and diagnostic laparocentesis were performed repeatedly — the ascitic fluid was an exudate (serum-ascitic albumin gradient — dance of deformed mesothelial cells was also noted. According to the instrumental examinations (ultrasound, computed tomography with intravenous contrast), signs of liver cirrhosis and portal hypertension were not reliably detected. However, thickening of the parietal peritoneum and infiltration of the peritoneal sheets were noteworthy. This clinical picture was suspicious for mesothelioma/peritoneal carcinomatosis. To clarify the nature of the changes, positron emission tomography with computed tomography (PET-CT) was performed. The results showed increased accumulation of the radiopharmaceutical agent along the peritoneum. The patient underwent therapeutic and diagnostic laparoscopy with biopsy. Based on the biopsy and immunohistochemical study, a diagnosis of epithelioid mesothelioma of the peritoneum was made. Polychemotherapy was started, five courses have been completed to date. The patient’s condition has improved, ascites has completely regressed, and abdominal pain practically does not bother him. In dynamics, PET-CT shows significant regression of mesothelioma foci and its metabolic activity.

Conclusion. The presence of ascites in a patient without signs of independent liver disease and portal hypertension serves as a reason for conducting an extensive differential diagnosis with a step-by-step examination to exclude malignant lesions of the peritoneum, in particular its primary tumor — mesothelioma.

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