Ascites: it is not all alcohol-a case of constrictive pericarditis.

To cite: Champsi A, Ali M. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2016-215021 DESCRIPTION A 43-year-old man was referred to a specialised liver unit with progressive abdominal distension and sarcopoenia. He had a background of moderate-to-high alcohol intake. His exercise tolerance was appropriate for his age, and he denied having had exertional dyspnoea or orthopnoea. On examination, there was shifting-dullness of his abdomen, bilateral pitting oedema, an elevated jugular venous pressure and sarcopenia. Other than having clinical ascites, there were no stigmata of liver disease. His observations were stable, and urine output acceptable. His blood tests revealed an acute derangement in his transaminases. A full liver screen was unremarkable in revealing a possible aetiology for this derangement. An abdominal ultrasound scan showed a large amount of ascites, in the presence of a normal liver morphology and patent hepatic vessels. His chest X-ray and ECG (figure 1) were unremarkable. Ascitic fluid demonstrated a transudative picture with a high serum-ascites albumin gradient; samples were negative for tuberculosis or malignancy. To establish cardiac ventricular function, a transthoracic echocardiogram (TTE) was performed. This showed normal right ventricular dimensions with good systolic function, a mildly dilated right atrium and left ventricular ejection fraction (LVEF) of 57±5%. A subsequent CT Thorax (figure 2) and cardiac-MRI revealed features in keeping with constrictive pericarditis (figure 3) (video 1). Invasive haemodynamic evaluation during cardiac catheterisation confirmed this diagnosis. An uneventful surgical pericardiectomy was performed, with no postoperative complications. A repeated TTE 2 weeks postoperatively demonstrated good biventricular function; LVEF was 85%. Histology demonstrated end stage, chronic fibrosing (‘obliterative’) pericarditis with no