Pulmonary Embolism Presenting with Ascites and Abdominal Pain
Abdominal pain as a presenting symptom of pulmonary embolism is uncommon and not well-quantified in major guidelines, though case reports document it occurs; ascites specifically as a PE presentation is exceptionally rare and not described in standard PE literature. 1, 2
Frequency of Abdominal Pain in PE
The 2019 ESC/ERS guidelines do not list abdominal pain among the typical presenting symptoms of PE, which primarily include dyspnea (72% of cases), chest pain (38-52%), syncope (19%), and hemoptysis 1, 3. Abdominal pain is explicitly described as an "uncommon" and "atypical" presenting symptom in the published literature 2, 4, 5.
Key Clinical Context:
- The typical PE presentation focuses on cardiopulmonary symptoms: dyspnea, pleuritic chest pain, syncope, and hemoptysis, with no mention of abdominal symptoms in major diagnostic guidelines 1, 3
- Multiple case reports from 2012-2020 describe abdominal pain presentations as "rare," "atypical," and "unusual," suggesting this occurs infrequently enough to warrant individual case documentation 2, 4, 5, 6
- One case series specifically notes that abdominal pain "is not currently included in the symptoms of PE in textbooks and guidelines" 6
Ascites and PE: An Exceptionally Rare Association
Ascites is not mentioned as a presenting feature of PE in any of the major guidelines or case reports reviewed 1, 3. This represents an extraordinarily uncommon presentation if it occurs at all.
Pathophysiologic Considerations:
While abdominal pain in PE can occur through several mechanisms, ascites would require:
- Severe right ventricular failure with systemic venous congestion (seen only in massive PE with hemodynamic instability) 1
- Hepatic congestion from acute cor pulmonale
- This would typically present as high-risk PE with hemodynamic instability, not isolated ascites 1, 3
Mechanisms of Abdominal Pain in PE
When abdominal pain does occur with PE, documented mechanisms include:
- Right upper quadrant pain from hepatic congestion due to right ventricular dysfunction and increased central venous pressure 2, 4, 6
- Referred pain from diaphragmatic pleural irritation when peripheral emboli cause pleural-based infarction 2, 4
- Flank pain from pulmonary infarction affecting the lower lobes with diaphragmatic irritation 7
- Visceral pain from mesenteric venous congestion in severe cases 5
Critical Clinical Pitfall
The primary danger is that abdominal pain presentations lead to misdiagnosis and delayed treatment, which can be catastrophic 2, 4, 5, 6. Case reports document initial misdiagnoses as:
Diagnostic Approach When PE is Suspected:
- Maintain high clinical suspicion even with atypical presentations, particularly in patients with VTE risk factors 2, 4, 6
- Apply Wells or revised Geneva score regardless of presenting symptom 1
- Do not rely on normal oxygen saturation to exclude PE—up to 40% of PE patients have normal SaO2 1, 8
- Proceed with D-dimer (if low-to-intermediate probability) or CTPA (if high probability) based on clinical probability scoring 1, 8
- Incidental pulmonary findings on abdominal CT imaging should prompt consideration of PE 7
Bottom Line
Abdominal pain occurs rarely enough in PE to be considered atypical and worthy of case report documentation, with no quantified frequency available in major studies. Ascites as a PE presentation is not documented in standard literature and would be extraordinarily rare, likely only occurring in the context of massive PE with severe right heart failure and hemodynamic compromise.