Step by step clinical diagnosis

ABSTRACT

A 54-year-old woman Para 5 was admitted to the hospital because of increasing abdominal enlargment. She felt well until a year ago, when abdominal distention gradually developed. In abdominal ultrasongraphy a coarse, echogenic liver and ascites was detected, the spleen was enlarged and other intraabdominal organs were normal. Abdominal paraeentesis was performed. Serum-aseites albumin gradient was greater than 1.1 gr/dl [high serum-ascites albumin gradient]. Laboratory-tests for evaluating the etiology of cirrhosis revealed HBs Ag Neg, HBc Ab Neg, Hcv Ab Neg, Anti HBs Pos. ASMA [anti smooth muscle antibody] Neg ANCA [anti neutrophilic cytoplasmic antibody] Neg ANA [anti nuclear antibody] Neg AMA [anti mitochondria! Antibody] Neg SPEP [serum protein electrophoresis] Normal range The patient had no history of hepatotoxic drug usage. In upper GI endoscopy two columns grade II varicose veins were seen. Based on the history and para clinic evaluation cryptogenic cirrhosis was the most probable diagnosis. The patient underwent medical therapy with furosemide and spironolactone, and in regular follow up amount of ascites was under control. A month ago the amount of ascites increased and several therapeutic paraeentesis were performed. Ascites analysis showed high serum-ascite albumin gradient and negative cytology for malignancy. Ultrasonography reported multiple focuses on peritoneal surface with seeding like appearance, cirrhotic liver, enlarged spleen and massive ascites, normal kidneys and uterus and ovaries.Tumour markers measurement revealed CEA= 0.3 [Normal range= 0-5 ng/ml] alpha FP= 0.4 [Normal range= 0-10 lU/ml]CA 125- 244 [Normal range- 0-35 lU/ml] Abdominal and pelvic CT scan didn't show any tumoural lesion and no paraaortic lymphadenopathy. Trans vaginal sonography reported normal uterus and ovaries. Further tumour marker analysis revealed Elevated serum level of CA 125 to 414 lU/ml CA 15 - 3 = 27 [normal = up to 40 lU/ml] CA 19 - 9 = 25 [normal = up to 40 lU/ml]. A week later level of CA 125 decreased to 262. Therefore we obtained fluctuating level of CA 125, normal CT scan and normal level of other tumour markers. We found in papers from other countries in the same situation that they performed laparotomy but they found nothing except cirrhosis [1]. In some articles CA 125 presented as a marker of ascites in patients with liver cirrhosis [2]. Some authors suggested that quantification of CA 125 in peritoneal fluid [PCA125] and serum [SCA125] can differentiate between cancer cases and non cancer disease, and they found that ratio of PCA125 to SCA125 [P/S CA125] was significantly lower in non cancer patients than that in cancer ones. [If the ratio is upper than five the risk of malignancy increased] [3]. We quantified CA125 level simultaneously in peritoneal fluid and serum PCA125 - 210, SCA125 = 250, P/S CA125 - 0.84. The ratio of 0.84 was predictive of a benign disease. In an overview to our patient, we had one sonography that reported seeding like appearance in peritoneal surface, but in CT scan no lesion was detected. Fluctuating level [increase - decrease] of CA125 and low P/S ratio, normal level of other tumour markers, made us to come to the final step of laparoscopic examination and biopsy to determine whether it is malignant or benign. In laparoscopic examination no cancerous lesion or fibrin deposit or tuberculosis granoluma with normal omentum and cirrhotic liver detected. Multiple biopsies were taken from peritoan beside liver which reported normal [no 159104]. We came to this conclusion that in cirrhotic patient with ascites the elevated level of CA125 with normal level of other tumour markers and low P/S ratio and no malignant finding in imaging is suggestive of a benign process, as described in other articles. More studies on this matter should be performed in order to prevent the unnecessary laparatomies