Ascites and diarrhea.

male who presented with diarrhea, abdominal pain, ascites, and edema while travelling in Egypt, and was consequently diagnosed with liver cirrhosis with portal hypertension. He had already presented to the emergency room with edema. The physical exam revealed a distended, soft, non-tender abdomen with positive ascitic wave, as well as edema in the lower limbs. He was discharged on a salt-free diet, compression pantyhose, and advice to undergo further testing by his primary care physician. An ultrasonogram performed in Egypt revealed homogeneous hepatomegaly with no space-occupying lesions, a 16-mm portal vein, bile bile mud, and overt ascites. Two months later the patient attended the gastroenterology clinic with suspicion of liver cirrhosis. He reported asthenia, weight loss (5 kg), malleolar edema, and light-colored soft feces for the last few months. His medical history included: hepatitis A during childhood, and three doses of VHB vaccine. A relative of his had been diagnosed with autoimmune liver disease. He reported no alcohol ingestion. The patient produced lab test results with interestingly normal transaminase levels. Physical exploration revealed a hard, non-tender hepatomegaly but no evidence of ascites or edema. New lab tests showed: GOT 31 IU/l, GPT 39 IU/l, GGT 7 IU/l, albumin 2.9 g/dl, total bilirubin 0.4 mg/dl, iron 88 μg/dl, ferritin 3.7 ng/ml, copper 65 μg/dl, ceruloplasmin 17 mg/dl, urine Na 90 mEq/l, urine K 25 mEq/l, Hb 13.8 g/dl, platelets 325,000/μl, WBCs 7,400 μl and normal differential, prothrombin activity 66%, TTPA 34, antismooth muscle antibodies 1/20, and negative anti-nuclear, anti-mitochondrial, and anti-LKM antibodies. Amylase 85 U/L, urine copper and 24-hour urine porphyrins within the normal range, and negative c-ANCA and p-ANCA. Anti-gliadin IgG antibodies 5.5 IU/ml (normal < 2.5 IU/ml), anti-gliadin IgA antibodies 0.86 IU/ml (normal < 1.5 IU/ml). Vitamin B12 and folic acid levels: normal. Serologic tests for hepatotropic viruses were positive for hepatitis A virus (IgG antibodies). AntiHBs antibodies were also positive. Thyroid hormones were within the normal range. A gastroduodenal radiographic study and intestinal follow-through were obtained that revealed no lesions, and a new abdominal ultrasonogram revealed a liver with irregular contour, homogeneous echogenicity, and no space-occupying lesions or ascites; patent portal vein, 13.7 cm in diameter, with hepatopetal flow (21 cm/s), and 13-cm spleen with a bipolar axis. No free fluid was identified within the abdominal cavity. Ultrasonographic judgment: image suggestive of chronic liver disease with portal dilation. Gastroscopy revealed no pathological findings and specifically no esophageal varices or other evidence of portal hypertension was identified; the second portion of the duodenum had normal morphology. Based on these data a previously performed lab test and exploration were repeated, which proved diagnostic.