A0056 - Gallbladder Adenocarcinoma Ascites Masquerading as Intrahepatic Portal Hypertension

Sanya Goswami, MD¹, Mohammad Almeqdadi, MD², Qi Yu, MD^3
1NYC H+H Kings County/SUNY Downstate Medical Center, Brookyln, NY; ²NYC H+H Kings County/SUNY Downstate Medical Center, Brooklyn, NY; ³NYC Health + Hospitals/King's County, SUNY Downstate, Brookyn, NY

Introduction: Gallbladder cancer has two patterns of growth. The more common type is infiltrative growth, and the less common type is exophytic growth. Infiltrative growth can cause deep ulcerations that lead to fistula formation with adjacent structures, such as the liver. Exophytic growth displays a pathognomonic cauliflower appearance invading the gallbladder wall. Risk factors include chronic inflammation, usually secondary to gallstones or infection.

Case Description/Methods: Here we present a case of a 57-year-old male with gallbladder adenocarcinoma s/p laparoscopic cholecystectomy and section 4b and 5 hepatectomy, cirrhosis most likely secondary to HCV with ascites of unknown origin complicated by recurrent SBP refractory to antibiotic therapy. On initial presentation, vital signs were largely unremarkable with physical examination remarkable for markedly distended, non-tender abdomen, with a positive fluid wave and shifting dullness. Laboratory findings revealed body fluid studies with a SAAG ratio less than 1.1 indicating malignancy, but a high hepatic venous pressure gradient pointing to portal hypertension, with multiple cytology findings negative for malignant cells, however with good synthetic liver function. CT abdomen pelvis upon presentation was unremarkable, and consistent with previous imaging findings of known hepatectomy. After repeated paracentesis and multiple courses of antibiotic therapies for SBP, with recurrent ascites, complicated by hyponatremia with no mental status changes, further management of the case involved interventional radiology placing a Denver shunt to control the ascites. After a couple of months, the patient was followed up and found to have progression of disease with cancer seeding into the peritoneum with omental caking.

Discussion: We strongly believe the patient’s recurrent ascites of unknown origin was most likely a case of recurrent malignancy in ascitic fluid, masquerading as intrahepatic portal hypertension. We hope that this case report highlights that although in the setting of poorly differentiated gallbladder adenocarcinoma with local metastasis and negative margin resections, malignant ascites can occur and must not be mistaken for portal hypertension given the conflicting SAAG ratio and HPVG.


Disclosures:


Sanya Goswami, MD¹, Mohammad Almeqdadi, MD², Qi Yu, MD³. A0056 - Gallbladder Adenocarcinoma Ascites Masquerading as Intrahepatic Portal Hypertension, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.