Clinical Medicine 2019 Vol 19, No 2: s73 CLINICAL

A r a r e c a s e o f a s c i t e s

Authors: S h u a n n S h w a n a , A d n a n U r R a h m a n a n d E l i z a b e t h S l o w i n s k a

A i m s most cases depends on whether it is idiopathic or secondary. The mainstay of treatment is corticosteroids; if there is no response, A 69-year-old gentleman presented with a 5-week history of immunosuppressive therapy can be used. Case-series data exist, . He had a past history of diabetes and which show that high-dose corticosteroids like prednisolone are myocardial infarction, and was an ex-smoker with no significant effective in reducing the chronic inflammatory response caused by history of alcohol intake. Examination demonstrated a distended, retroperitoneal fibrosis; however, there is a high rate of recurrence non-tender with shifting dullness, no and once the steroids are withdrawn. Mycophenolate mofetil in addition no signs of chronic disease. to corticosteroids has been shown to reduce duration of steroid use without affecting the efficacy and reduces disease recurrence. ■ M e t h o d s Investigations included an ultrasound scan of the abdomen, an Conflict of interest statement ascitic tap, a computed tomography (CT) of the abdomen/pelvis N o n e d e c l a r e d . and a CT-guided biopsy.

R e s u l t s The ascitic tap revealed chylous with a high serum ascites albumin gradient of >1.1 g/dL, indicating a non-peritoneal cause of ascites. Cytology revealed no evidence of malignancy. The CT of the abdomen revealed a mildly enhancing soft tissue mass, encasing the mesenteric and renal vessels and the upper abdominal aorta and also the left peritoneal space; appearances were suggestive of lymphoproliferative disorder. The CT-guided biopsy showed reactive changes consistent with retroperitoneal fibrosis. Immunohistochemistry done at University College London showed no evidence of immunoglobulin G4 (IgG4) disease. The patient was commenced on prednisolone and azathioprine. He failed to tolerate azathioprine, which was then stopped. Treatment with prednisolone failed to slow the rate of reaccumulation of the ascites, and he continued to require frequent abdominal paracentesis.

Conclusions Chylous ascites has rarely been reported as a presenting feature of retroperitoneal fibrosis. Retroperitoneal fibrosis may be idiopathic in 70% of cases or a secondary condition. The incidence of the idiopathic form is 0.1 per 100,000 person-years with a prevalence of 1.4 per 100,000 population. The primary method used for diagnosis of retroperitoneal fibrosis is CT; biopsies are performed in cases of unusual presentation and to exclude malignancy and IgG4-related pathology. Treatment of retroperitoneal fibrosis in

Author: P r i n c e C h a r l e s H o s p i t a l , M e r t h y r T y d fi l , U K

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