Introduction 40 years old married goldsmith presented with features of numbness of both lower limbs, swelling of the neck, bilateral pedal oedema and abdominal distension of 4 months duration. In addition he had asthenia, effort dyspnoea and pigmentation. Systemic inquiry revealed no other significant symptoms and he was on treatment for hypertension. He was a non-alcoholic and a non-smoker. He had many social and psychological problems due to his current illness.

Examination revealed mild pallor, pigmentation not involving oral mucosa but involving skin creases, generalised lymphadenopathy in the cervical, supraclavicular and inguinal areas rubbery and non-discrete in certain areas, leuconychia without clubbing, ankle oedema. CVS and respiratory system examination were normal. Abdomen revealed non-tender hepatomegaly 4 cm below right costal margin shifting dullness, while CNS examination revealed presence of peripheral neuropathy with bilateral foot drop without thickened nerves and bilateral papilloedema.

Following were the results of laboratory investigations;

• FBC: Hb-9.3 g/dl, MCV-70.2 fl and rest normal.

• LFT: normal. Renal profile normal.

• ESR:40 mm first hour, C-RP 48 mg/dl.

• FBS-100 mg/dl. Normal ferritin, calcium and ceruloplasmin levels.

• Clotting profile: INR-1.6, rest normal.

• UFR normal. HIV screening negative. CXR-PA normal.

• Abdomen and pelvic USS: minimal hepatomegaly and splenomegaly with ascites.

• Mantoux negative.

• OGD: no evidence of portal hypertension.

• Bone marrow normal.

• Nerve conduction study and EMG: severe demyelinating sensory and motor neuropathy.

• 2D echo: moderate LVH and pulmonary hypertension with small pericardial effusion.

• TSH- 23.8 μiu/l (0.4–4.0 μiu/l)

• Ascitic fluid analysis: 64.5 g/l, white cells- 344/mm³ 90% lymphocytes and 10% neutrophils. LDH and amylase levels normal. Screening for mycobacterium negative.

• Liver biopsy: interphase hepatitis.

• Immunoglobulin Profile – elevated α 2 Globulins and a mild polyclonal gammopathy

• Free κ light chains 569.0 mg/dl (138–375)

• Free λ light chains 258.7 mg/dl (93–242)

• Lymph node biopsy revealed unifying diagnosis which was compatible with other clinical and laboratory findings.

• The patient was treated with a single drug for 6 months which resulted in improvement of his clinical features and resolution of ascites.

Conclusion Ascites is a common condition encountered by a Gastroenterologist with or without other signs, and the aeotiology could be unusually extraordinary as in this report with an unusual therapeutic strategy.

Methods BSG – interactive case presentation

Results BSG – interactive case presentation

Conclusion BSG – interactive case presentation