Shock From Hemorrhagic Ascites in a Non-cirrhotic Patient With Isolated High-Output Right Heart Failure

A 49-year-old male patient with multiple comorbidities, including end-stage renal disease (ESRD), diabetes mellitus, obesity, and obstructive sleep apnea, presented to the emergency department with clinical signs of hemorrhagic shock in the setting of volume overload. After initial stabilization, he underwent paracentesis and was diagnosed with hemorrhagic ascites (HA). Post-discharge, the patient was re-admitted multiple times due to refractory HA in the setting of poor volume management. Cirrhosis was ruled out with biopsy, and subsequent workup following his initial presentation eventually revealed high-output right heart failure in the setting of severe pulmonary hypertension (undiagnosed on initial presentation). Recognizing acute presentations of hemorrhagic ascites secondary to cardiac etiology can prove challenging in a patient with long-standing ESRD in the absence of liver cirrhosis because reported cases in the literature for this specific subset of patient population are seldom. This case will discuss the methodical approach in diagnostic workup taken and emphasize the importance of considering right heart failure as a potential differential, even if a patient had no significant cardiac history on file. More research is needed to further investigate the connection between right heart failure with pulmonary hypertension and hemorrhagic ascites.