Bezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D. Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report. World J Clin Cases 2019; 7(20): 3266-3270 [PMID: 31667177 DOI: 10.12998/wjcc.v7.i20.3266]
Corresponding Author of This Article
Danko Mikulić, FEBS, MD, PhD, Attending Doctor, Surgeon, Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zajčeva 19, Zagreb 10000, Croatia. danko.mikulic@zg.t-com.hr
Research Domain of This Article
Transplantation
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Miran Bezjak, Branislav Kocman, Stipislav Jadrijević, Tomislav Bubalo, Danko Mikulić, Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
Hrvoje Gašparović, Division of Cardiology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
Anna Mrzljak, Tajana Filipec Kanižaj, Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
Darko Vujanić, Division of Cardiology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
Author contributions: Bezjak M wrote the manuscript. Mikulić D and Gašparović H were the patient’s operators. Mikulić D reviewed the literature and contributed to manuscript drafting. Mrzljak A reviewed the literature and contributed to manuscript drafting. Mikulić D, Kocman B, Jadrijević S and Filipec Kanižaj T were responsible for the revision of the manuscript for important intellectual content. Vujanić D was responsible for cardiological treatment and contributed to diagnosis. Bubalo T contributed to manuscript drafting. All authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Danko Mikulić, FEBS, MD, PhD, Attending Doctor, Surgeon, Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zajčeva 19, Zagreb 10000, Croatia. danko.mikulic@zg.t-com.hr
Telephone: +385-1-2431390 Fax: +385-1-2431394
Received: May 28, 2019 Peer-review started: June 4, 2019 First decision: August 1, 2019 Revised: August 23, 2019 Accepted: October 5, 2019 Article in press: October 5, 2019 Published online: October 26, 2019 Processing time: 151 Days and 8.6 Hours
Abstract
BACKGROUND
Refractory ascites is a rare complication following orthotopic liver transplantation (OLT). The broad spectrum of differential diagnosis often leads to delay in diagnosis. Therapy depends on recognition and treatment of the underlying cause. Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure. In the advanced stages of the disease, hepatic congestion leads to formation of ascites. In patients after OLT, cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.
CASE SUMMARY
We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis. Prior to transplantation the patient had a minimal amount of ascites. The transplant procedure and the early postoperative course were uneventful. Standard post-transplant work up failed to reveal any typical cause of refractory post-transplant ascites. The function of the graft was good. Apart from atrial fibrillation, cardiac status was normal. Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema. Ascites was still prominent. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology. Diagnostic paracentesis was suggestive of cardiac ascites, and further cardiac evaluation showed typical signs of constrictive pericarditis. Pericardiectomy was performed followed by complete resolution of ascites. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.
CONCLUSION
Refractory ascites following liver transplantation is a rare complication with many possible causes. Broad differential diagnosis needs to be considered.
Core tip: Refractory ascites following liver transplantation is a rare complication with many possible causes. Constrictive pericarditis is a disease characterized by clinical signs of right-sided heart failure which in the advanced stages can lead to hepatic congestion and formation of ascites. As a cause of refractory ascites it is easily overlooked and it requires a high degree of clinical suspicion. We present an uncommon case where refractory ascites occurred after successful liver transplantation for alcoholic cirrhosis and was caused by previously unknown constrictive pericarditis. Pericardiectomy led to complete resolution of the ascites, and the patient remained symptom free until today.
