A liver puzzle

The anasarca and ascites could be explained by right heart failure induced portal hypertension ( this is possible without cirrhosis). An ascites total protein > 2.5 mg/dL would support a diagnosis of right heart failure induced portal hypertension. The TP> 2.5 mg/dL for chf induced ascites holds true only when the SAAG suggests portal HTN as a cause of ascites. In other words, ascites with a SAAG of 0.5 and a TP of 3 would NOT suggest CHF as a cause. By the way, when the clinical picture looks like right heart failure ( severe anasarca) always consider constrictive pericarditis in the DDX. A clue would be pericardial calcifications seen on chest CT or CXR. Also check for risk factors for constriction ( any pericardial violation- most common would be open heart surgery. also h/o acute pericarditis, mediastinal radiation or trauma or even TB.) Gold standard for diagnosing constriction is a right heart cath but you can find clues with an ECHO or even better, a cardiac MRI.

The Pco2 may be elevated from acute resp failure in the setting of too high an FI02 if he is a CO2 retainer from COPD. His resp failure could be from COPD/CHF.

Did he get IV albumin with his paracentesis? If so, then I wonder if the IV albumin drew fluid in from the interstitial space to the intravascular space. If so, then this sudden increase in intravascular fluid may have led to flash pulmonary edema.

His elevated Hco3 at baseline could be from chronic resp acidosis or from contraction alkalosis from chronic diuretic therapy.