The Heart of the Matter: A Case of Massive Pedal Edema Erroneously Attributed to Liver Cirrhosis.

Liver cirrhosis is commonly diagnosed with etiologies such as viral hepatitis, alcohol-related liver disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). However, less common causes should be considered, especially in atypical presentations or suboptimal treatment responses. A 67-year-old man presented with massive bilateral pedal edema unresponsive to furosemide. He had well-controlled diabetes and hypertension but no history of alcohol use. Laboratory tests showed normal renal function, mild transaminitis, and mild thrombocytopenia. Imaging revealed liver morphology suggestive of cirrhosis, which prompted the presumptive diagnosis of metabolic-associated steatohepatitis (MASH). Despite diuretic therapy, the patient's edema worsened, necessitating repeated hospital admissions for intravenous diuresis. Measurement of transhepatic pressures showed findings consistent with portal hypertension, but the degree of edema was disproportionate to the hepatic venous pressure gradient. Liver biopsy showed sinusoidal congestion suggesting cardiac causes of portal hypertension. Subsequent cardiac evaluation, including left and right heart catheterization and cardiac MRI, revealed constrictive pericarditis. The patient then underwent pericardiectomy, leading to substantial improvement in symptoms allowing cessation of diuretic therapy. The overlap of symptoms between cardiopulmonary and hepatic diseases can complicate diagnosis. Cardiac cirrhosis, though often asymptomatic, should be considered in patients with unexplained peripheral edema. Diagnostic challenges include normal echocardiograms and the need for advanced imaging. Careful evaluation and consideration of atypical presentations are crucial, with gastroenterologists playing a vital role in identifying cardiac conditions masquerading as primary liver disease.