An older woman with abdominal pain and ascites

A woman in her 70s presented with a two week history of fever, sharp upper abdominal pain, and bloating. She also reported a weight loss of 2 kg, reduced appetite, and bilateral calf swelling over the previous six weeks. She had seen no change in bowel frequency or form, rectal or vaginal bleeding, and had no family history of cancer. Her history included gallstones and hypertension.

On examination she was alert and afebrile and had no cachexia or jaundice. Examination showed generalised abdominal tenderness with no signs of peritonitis, and bowel sounds were present. Ascites and bilateral lower limb oedema to the knees were noted. Murphy’s sign was negative, with no palpable masses or lymphadenopathy.

Her vital signs were within normal limits. An electrocardiogram showed normal sinus rhythm. On admission, blood investigations were requested, including tumour markers (table 1). Abdominal and pelvic ultrasonography showed a …