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The case of an adult male who came to clinical evaluation because of an abundant ascites without any obvious cardiac or hepatic explanation is reported. The exudative characteristics of the ascitic fluid, the elevated serum-ascites albumin gradient, some electrocardiographic anomalies, hypercholesterolemia and a slight macrocytic anemia prompted a clinical diagnosis of probable hypothyroidism. This was also due to an anamnesis of remote antithyroid radiometabolic treatment. The serum hormone levels and the ultrasonogram of the gland confirmed the diagnosis. Hormonal substitutive therapy led to thyroid-stimulating hormone normalization and to a progressive decrease of the ascites, that eventually disappeared. This case, which involves a rare manifestation of hypothyroidism, underscores the need to consider thyroid diseases in the differential diagnosis of ascites and to include thyroid-stimulating hormone dosage among the laboratory tests to be ordered when suspicious clinical or biochemical data are present (mainly, the exudative aspect of the ascites).

Hyponatremia complicates ascitic hepatic cirrhosis with frequency and gravity related to the gravity of the cirrhosis itself. When hyponatremia develops, it worsens the already present secondary hyperaldosteronism and makes therapy with spironolactone inefficacious. From a pathophysiologic viewpoint a pathogenetic role in determining hyponatremia is attributable to the reduced plasmatic renal perfusion; in several patients a syndrome of inappropriate ADH secretion develops. Other neurohormonal systems (catecholamines, prostaglandins, natriuretic hormones) are probably very important in modifying renal hemodynamics and renal tubular function. In some patients a causative role for hyponatremia is attributable to iatrogenic factors (e.g.: diuretics). From a therapeutic viewpoint, we examine some schedules, pharmacologic or not, that, however, are far from being useful for all patients. We discuss, mainly, water restriction, osmotic diuretics with or without loop diuretics, loop diuretics followed by sodium reintegration and concentration-reinfusion of ascites or application of peritoneovenous shunt.