38 year old woman with abdominal distention

Grace Huang on Nov 16, 2014

Ms. C is a 38 year old woman presents to your clinic with the complaint of abdominal distention and bloating. She reports that she has had persistent bloating symptoms for the past 2-3 weeks.

She notes that over the past few years, she occasionally has episodes where she will feel bloated but which normally resolve after a few days. She is unsure whether or not this is related to her menstrual cycle. Unlike previous episodes, she has also grown visibly distended to her friends and colleagues and is no longer able to fit in her clothes. She is uncomfortable throughout the day and experiences little relief with position changes or Gas-X. She continues to have normal bowel movements and flatus daily. She denies any vomiting or cramping. She notes decreased appetite secondary to feeling bloated, but she has had a 10 pound weight gain over the last month. She denies any changes to her menstrual cycle.

The patient has a family history significant for colon cancer in her father, diagnosed at age 53. 

 

  • Temp  37 C
  • HR  88
  • BP  115/75
  • RR  18
  • O2  0% on Room Air

On physical examination, she is a mildly ill appearing female in no apparent distress. Her abdominal examination shows distention and you are unable to appreciate a fluid wave. Abdomen is soft with mild RUQ tenderness. You are unable to assess for HSM given the distention. No rebound tenderness or guarding. Physical exam is otherwise unremarkable and shows no signs of caput medusa, palmar erythema, asterixis, or jaundice.

An acute abdominal series is ordered, which reveals increased haziness over the abdomen, concerning for ascites. There is no significant fecal loading appreciated nor free intraperitoneal air. When compared to an abdominal XR performed 1 year ago when the patient presented to the ER with abdominal pain (patient was diagnosed with viral gastroenteritis), there is a new left pleural effusion with left basilar lobe atelectasis. 

Abdominal ultrasound is of limited value due to extensive fluid collection, and patient refuses vaginal ultrasound.

The patient undergoes a diagnostic paracentesis. Which of the following results are concerning for malignancy?

Select all that apply
Expand all answers
Increased amylase in ascitic fluid
Incorrect. Increased amylase likely represents pancreatic ascites. (1)


Bloody fluid
Correct. Bloody fluid is concerning for malignancy and the test should be followed up with a CT abdomen/pelvis as well as cytology of the ascitic fluid. Blood fluid may also represent a traumatic tap, cirrhotic ascites, or congestive heart failure. There is another answer choice that could be correct. (1)


Increased neutrophil count
An increased neutrophil count in ascitic fluid likely represents an infectious process. (1)


Serum albumin = 3.5, ascitic fluid albumin = 2.8
This woman's SAAG score is 0.7. SAAG scores of <1.1 have a differential diagnosis including malignancy, peritoneal carcinomatosis, TB, bowel obstruction/infarction, and pancreatic ascites. There is another answer choice that could also be correct. (1)


  1. (1) McGibbon A, Chen GI, Peltekian KM, Veldhuyzen van Zanten S. An Evidence-Based Manual for Abdominal Paracentesis. Dig Dis Sci. March 2007; 52:3307-15.

Ms. C is a 38 year old woman presents to your clinic with the complaint of abdominal distention and bloating. She reports that she has had persistent bloating symptoms for the past 2-3 weeks.

She notes that over the past few years, she occasionally has episodes where she will feel bloated but which normally resolve after a few days. She is unsure whether or not this is related to her menstrual cycle. Unlike previous episodes, she has also grown visibly distended to her friends and colleagues and is no longer able to fit in her clothes. She is uncomfortable throughout the day and experiences little relief with position changes or Gas-X. She continues to have normal bowel movements and flatus daily. She denies any vomiting or cramping. She notes decreased appetite secondary to feeling bloated, but she has had a 10 pound weight gain over the last month. She denies any changes to her menstrual cycle.

The patient has a family history significant for colon cancer in her father, diagnosed at age 53. 

 

  • Temp  37 C
  • HR  88
  • BP  115/75
  • RR  18
  • O2  0% on Room Air

On physical examination, she is a mildly ill appearing female in no apparent distress. Her abdominal examination shows distention and you are unable to appreciate a fluid wave. Abdomen is soft with mild RUQ tenderness. You are unable to assess for HSM given the distention. No rebound tenderness or guarding. Physical exam is otherwise unremarkable and shows no signs of caput medusa, palmar erythema, asterixis, or jaundice.

An acute abdominal series is ordered, which reveals increased haziness over the abdomen, concerning for ascites. There is no significant fecal loading appreciated nor free intraperitoneal air. When compared to an abdominal XR performed 1 year ago when the patient presented to the ER with abdominal pain (patient was diagnosed with viral gastroenteritis), there is a new left pleural effusion with left basilar lobe atelectasis. 

Abdominal ultrasound is of limited value due to extensive fluid collection, and patient refuses vaginal ultrasound.

The patient undergoes a diagnostic paracentesis. Which of the following results are concerning for malignancy?

Select all that apply
Expand all answers
Increased amylase in ascitic fluid
Incorrect. Increased amylase likely represents pancreatic ascites. (1)


Bloody fluid
Correct. Bloody fluid is concerning for malignancy and the test should be followed up with a CT abdomen/pelvis as well as cytology of the ascitic fluid. Blood fluid may also represent a traumatic tap, cirrhotic ascites, or congestive heart failure. There is another answer choice that could be correct. (1)


Increased neutrophil count
An increased neutrophil count in ascitic fluid likely represents an infectious process. (1)


Serum albumin = 3.5, ascitic fluid albumin = 2.8
This woman's SAAG score is 0.7. SAAG scores of <1.1 have a differential diagnosis including malignancy, peritoneal carcinomatosis, TB, bowel obstruction/infarction, and pancreatic ascites. There is another answer choice that could also be correct. (1)


  1. (1) McGibbon A, Chen GI, Peltekian KM, Veldhuyzen van Zanten S. An Evidence-Based Manual for Abdominal Paracentesis. Dig Dis Sci. March 2007; 52:3307-15.

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