Carolyn Wilson, MD1, Nina Devas, MD2, Alyssar Habib, MD2, Maya Rosenberg, MD1, Katie Shen, MD3, Luke Frankl, MD1, Saif Laljee, MD1, Renee Williams, MD, MHPE, FACG2 1NYU Langone Health, New York, NY; 2NYU Grossman School of Medicine, New York, NY; 3New York University Langone Health, New York City, NY Introduction: Ascites typically presents as a complication of cirrhosis and portal hypertension; when cirrhosis is absent, the differential includes malignancy, infection, cardiac disease, nephrotic syndrome, and rarer hepatic or peritoneal conditions. We present a diagnostically complex case of persistent ascites in a young male with alcohol use disorder and biopsy-confirmed steatohepatitis without cirrhosis.
Case Description/
Methods: A 26-year-old male with alcohol use disorder was admitted following stab wounds and underwent exploratory laparotomy with cholecystectomy. Postoperatively, he developed kidney injury and diuretic-refractory ascites requiring frequent large-volume paracenteses. Ascitic fluid showed high protein, variable SAAG (low to high), negative cultures and cytology, and lymphocyte predominance without evidence of malignancy or lymphoma. Extensive workup was unrevealing: autoimmune and viral serologies, TB, and parasitic studies were negative. BNP was mildly elevated; thyroid studies revealed worsening hypothyroidism, though endocrinology thought myxedema ascites were unlikely. Norovirus was detected, but other infectious stool studies were negative. Serum ceruloplasmin and A1AT levels were normal. Imaging (ultrasound, CT, HIDA scan) demonstrated large-volume ascites and fatty liver without cirrhosis or biliary leak. Echocardiography and cardiac catheterization revealed preserved EF and only mild post-capillary pulmonary hypertension. Two liver biopsies revealed advanced steatohepatitis with bridging fibrosis, but no cirrhosis. Repeat hepatic venous pressure gradient (HVPG) was normal, excluding portal hypertension. Despite aggressive diuretics and robust urine output, his ascites has persisted. TIPS was ultimately deferred due to normal HVPG and portal pressures. A trial of resumed diuretics showed some benefit but limited by hypotension. Discussion: This case illustrates the diagnostic complexity of refractory ascites in the absence of cirrhosis. Findings suggest functional portal hypertension secondary to steatohepatitis or surgical decompensation, despite normal HVPG. SAAG variability may reflect inflammation or prior surgery, and HVPG may underestimate portal pressures in select contexts. Persistent ascites in such cases may require careful consideration of less desirable options such as peritoneal drains or peritoneovenous shunts Ascites can precede histologic cirrhosis in advanced steatohepatitis. A multidisciplinary approach is essential in evaluating ascites of unclear etiology.
Disclosures: Carolyn Wilson indicated no relevant financial relationships. Nina Devas indicated no relevant financial relationships. Alyssar Habib indicated no relevant financial relationships. Maya Rosenberg indicated no relevant financial relationships. Katie Shen indicated no relevant financial relationships. Luke Frankl indicated no relevant financial relationships. Saif Laljee indicated no relevant financial relationships. Renee Williams indicated no relevant financial relationships.
Carolyn Wilson, MD1, Nina Devas, MD2, Alyssar Habib, MD2, Maya Rosenberg, MD1, Katie Shen, MD3, Luke Frankl, MD1, Saif Laljee, MD1, Renee Williams, MD, MHPE, FACG2. P1768 - Refractory Ascites in Non-Cirrhotic Steatohepatitis: Diagnostic and Management Challenges, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
