Constrictive pericarditis presenting as isolated ascites
Crit Care Med
Learning Objectives: Constrictive pericarditis is thought to be a rare though underdiagnosed entity. Symptoms can be nonspecific, though most patients present with progressive heart failure symptoms. Here, we present a case of constrictive pericarditis presenting with ascites only. Methods: This is a 51-year-old male with no prior cardiac history, type II diabetes complicated by end-stage renal disease, and alcohol abuse who presented with abdominal swelling. Physical examination was notable only for ascites without other signs of decompensated liver disease or right-sided heart failure. Laboratory studies were nonspecific aside from elevated blood urea nitrogen and creatinine consistent with his end-stage renal disease status. Imaging demonstrated cirrhotic liver morphology on abdominal ultrasound. He underwent paracentesis with fluid studies consistent with portal hypertension. Liver biopsy demonstrated hepatic venous congestion without evidence of parenchymal disease. Attention then turned to non-cirrhotic causes of ascites. Transthoracic Doppler echocardiography demonstrated a restrictive filling pattern with exaggerated ventricular interdependence, without evidence of pericardial effusion. Computed tomography of the thorax demonstrated pericardial thickening. Cardiac catheterization demonstrated invasive hemodynamic findings consistent with constrictive pericarditis. The patient underwent pericardiectomy which was complicated by post-operative hypotension requiring vasopressor support. He was stabilized and ultimately discharged ten days post-procedure. Pathology was negative for malignancy, infectious organisms, or amyloidosis. He was seen in follow-up three weeks later and reported near total resolution of his symptoms. Results: Cirrhosis accounts for 80% of the causes of ascites. Ascitic fluid analysis consistent with portal hypertension can be secondary to noncirrhotic causes such as acute liver failure, Budd-Chiari syndrome, heart failure, or nephrogenic ascites. Our patient illustrates a unique presentation of constrictive pericarditis that manifested clinically with only ascites. Despite the lack of other clinical signs, a thorough evaluation allowed us to recognize and prevent life-threatening consequences. This case highlights the importance of recognizing varying clinical presentations of potentially life-threatening disorders.