A 69 year old lady presents to the emergency department overnight with nausea, vomiting, and weight loss. This has been worsening for a period of weeks. She has now become confused and cannot tell you any of her past medical history.
On exam, you notice a healed midline laparotomy scar and some right upper quadrant fullness. Apart from a temperature of 38.1 degrees celsius, her vital signs are normal.
While waiting for blood test results, you decide to perform an abdominal ultrasound.
- Moderate left sided hydronephrosis and hydroureter.
- Large volume free fluid around the spleen.
This is an image of the right upper quadrant
- Coarse liver echotexture, likely related to either multiple metastases or cirrhosis.
- Intra-abdominal free fluid between liver and diaphragm.
- Small volume right pleural effusion.
- Intra-abdominal free fluid in this context is most likely ascites secondary to peritoneal metastases. A definite cause for hydronephrosis is not demonstrated. However, in this clinical context, distal ureteric obstruction from a pelvic lesion is most likely. Finally, her pleural effusion may be due to either lung metastases, or hypoalbuminemia of malignancy.
- This lady had recurrence of colonic adenocarcinoma with hepatic and peritoneal metastases, although ovarian, renal cell or cervical carcinoma could also give a similar picture. Her confusion was caused by concurrent spontaneous bacterial peritonitis, which did not present with typical features of sepsis.