Differential Diagnosis for a 63 YOF with Severe Ascites and ABD Pain

Single Most Likely Diagnosis

• Spontaneous Bacterial Peritonitis (SBP): Given the severe ascites, abdominal pain, and elevated WBC count (26.9), SBP is a strong consideration. The elevated AST and alkaline phosphatase levels also support liver dysfunction, which is often associated with ascites and increases the risk for SBP.

Other Likely Diagnoses

• Liver Cirrhosis with Complications: The patient's ascites, abdominal pain, and abnormal liver function tests (especially the elevated AST and alkaline phosphatase) suggest liver cirrhosis. The elevated MCV could indicate alcohol use, a common cause of cirrhosis.
• Hepatocellular Carcinoma: This could be a complication of cirrhosis, especially with severe ascites and abdominal pain. The elevated AST and alkaline phosphatase levels could also be seen in hepatocellular carcinoma.
• Budd-Chiari Syndrome: Although less common, this condition (hepatic vein thrombosis) could explain the ascites, abdominal pain, and liver function abnormalities, especially if there's a history of thrombophilia.

Do Not Miss Diagnoses

• Ovarian Torsion or Rupture: Although less likely given the age and presentation, ovarian torsion or rupture could cause severe abdominal pain and ascites. It's crucial to consider this diagnosis due to its urgency and potential for severe consequences if missed.
• Ruptured Hepatic Adenoma or Other Liver Mass: These conditions could cause acute abdominal pain and ascites, especially if there's bleeding into the peritoneal cavity.
• Intra-abdominal Infection (e.g., Perforated Viscus): Given the elevated WBC count, an intra-abdominal infection should be considered, as it requires immediate surgical intervention.

Rare Diagnoses

• Primary Biliary Cholangitis (PBC) or Primary Sclerosing Cholangitis (PSC): These autoimmune liver diseases could explain the abnormal liver function tests but are less likely given the acute presentation.
• Veno-occlusive Disease: A rare condition that could cause ascites and liver dysfunction, especially in the setting of bone marrow transplantation or certain medications.
• Abdominal Lymphoma: Could cause ascites, abdominal pain, and elevated liver function tests, although it's less common and would typically be associated with other systemic symptoms.