Last Resort

A 22-year-old man presented to a Canadian community hospital emergency department complaining of 2-3 weeks of abdominal pain and bloating associated with early satiety. He also noted weight loss of 20 pounds over the preceding months, leg and abdominal swelling with increased girth, and 1-2 loose, nonbloody stools per day.

Early satiety and bloating are nonspecific symptoms that can be due to gastroesophageal reflux disease, peptic ulcer disease, gastrointestinal obstruction, or gastroparesis. Weight loss in a young person, particularly if >5% of body weight, is concerning for a serious underlying medical issue. It could reflect reduced intake due to anorexia, odynophagia, or dysphagia or increased energy expenditure due to an inflammatory state such as infection or rheumatic disease. The etiology of the swelling needs to be elucidated. It may be due to increased hydrostatic forces as in heart failure, venous or lymphatic obstruction, or from lowered oncotic pressure resulting from hepatic disease, nephrotic syndrome, severe malnutrition (nonbloody loose stools), or a protein losing enteropathy.

The patient was transferred to a tertiary care center for closer access to specialty consultation. He described generalized abdominal pain increasing in intensity over three weeks; bilateral lower extremity, scrotal, abdominal wall, and sacral edema; and mild dyspnea on exertion. The early satiety was not associated with dysphagia, odynophagia, nausea, or vomiting. He denied fevers, chills, night sweats, nausea, vomiting, jaundice, easy bruising, orthopnea, paroxysmal nocturnal dyspnea (PND), or chest pain. His past medical history included asthma treated with fluticasone/salmeterol and albuterol. He was a Canadian of East Asian descent working as a plumber. He previously smoked three to four cigarettes per day for six years. He stopped smoking one month before presentation. He had one alcoholic beverage per week and smoked marijuana weekly. He denied any family history of similar symptoms or malignancy.The differential diagnosis for weight loss and anasarca is broad and includes malignancies, infectious diseases, rheumatic or inflammatory disorders, malabsorption, and advanced cardiac, renal, or liver disease. His history does not classically point in one direction. The mild dyspnea on exertion may be due to cardiac disease, but it is unlikely in the absence of orthopnea and PND. The dyspnea could be due to increased abdominal pressure if ascites are present, his underlying asthma, or another etiology such as anemia. Fevers, chills, and/or night sweats can be expected in infections and some malignancies, but their absence does not exclude infections and malignancies from the differential diagnoses. Particular attention should be paid to lymphadenopathy on the physical examination. The presence of an umbilical nodule (Sister Mary Joseph sign) could indicate a malignancy (gastrointestinal or lymphoma).

The differential diagnosis for weight loss and anasarca is broad and includes malignancies, infectious diseases, rheumatic or inflammatory disorders, malabsorption, and advanced cardiac, renal, or liver disease. His history does not classically point in one direction. The mild dyspnea on exertion may be due to cardiac disease, but it is unlikely in the absence of orthopnea and PND. The dyspnea could be due to increased abdominal pressure if ascites are present, his underlying asthma, or another etiology such as anemia. Fevers, chills, and/or night sweats can be expected in infections and some malignancies, but their absence does not exclude infections and malignancies from the differential diagnoses. Particular attention should be paid to lymphadenopathy on the physical examination. The presence of an umbilical nodule (Sister Mary Joseph sign) could indicate a malignancy (gastrointestinal or lymphoma).

On physical examination, his temperature was 38.1°C, heart rate was 138 beats per minute, blood pressure was 123/86 mm Hg, respiratory rate was 20 breaths per minute, and oxygen saturation was 97% on room air. He appeared uncomfortable and diaphoretic. No scleral icterus or jaundice was appreciated. There were no palpable cervical, axillary, or inguinal lymph nodes. Cardiac examination revealed tachycardia and no murmurs, rubs, gallops, or jugular venous distention. Abdominal examination revealed abdominal distention, diffuse tenderness to deep palpation, bulging flanks, and a positive fluid wave. Liver and spleen could not be palpated or percussed secondary to abdominal distention. He had pitting bilateral lower extremity edema that extended to and included the scrotum. Neurologic and pulmonary examinations were unremarkable.

His examination reveals low-grade fever, tachycardia, and diaphoresis. Whether this represents progression of his primary disease or he has acutely developed a superimposed infection is uncertain at this point. He has notable anasarca but no jugular venous distention, crackles, or S3 gallop. The lack of evidence of pulmonary edema or increased central venous pressure on physical examination increases the likelihood of cirrhosis, hypoalbuminemia, or obstruction (lymphatic or venous) and decreases the likelihood of heart failure as the etiology of his peripheral edema and likely ascites. Despite the prominence of gastrointestinal symptoms, he has neither jaundice nor stigmata of chronic liver disease. Periorbital edema, which may be present in nephrotic syndrome, is also absent. Although he has no palpable peripheral lymphadenopathy, malignancy remains a concern.