AB140. SOH23ABS_130. The role of diagnostic laparoscopy when all other diagnostic tests fail

Background: A 45-year-old gentleman presented with a 1-month history of abdominal pain, weight loss and anorexia. The patient was otherwise vitally stable with a normal clinical examination. There was no relevant medical, surgical, family or social history.

Case Presentation: Initial investigations were unremarkable excluding an elevated C-reactive protein (CRP). A Computed Tomography scan of the abdomen and pelvis revealed extensive ascites suspicious for malignancy and questionable thickening of the gastric antrum and sigmoid. Follow up gastroscopy and colonoscopy were normal. Two diagnostic taps were examined for cytology, culture and sensitivity. No suspicious cells were identified. Biochemistry analysis confirmed high protein ascites. Vasculitis and rheumatological panels were negative and carcinoembryonic antigen levels were within the normal range. His symptoms improved in hospital with an associated CRP reduction to 85 without intervention and he was discharged. A follow-up laparoscopy revealed a white, thickened peritoneum with multiple cystic-like lesions and large volume ascites. Intra-operative pictures are available. No obvious primary malignancy was identified, and provisional histology results report mucinous adenocarcinoma without a definitive primary source of malignancy. The patient has subsequently been referred to the Mater Misericordiae Hospital for consideration of cytoreductive surgery including hyperthermic intraperitoneal chemotherapy and peritonectomy.

Conclusions: This case underscores how in a time when diagnostics leans ever more heavily on imaging and biochemistry, the use of laparoscopy remains fundamental in establishing diagnoses in difficult clinical conundrums.

Keywords: Diagnostic laparoscopy; large volume ascites; mucinous adenocarcinoma; peritonectomy; hyperthermic intraperitoneal chemotherapy