Case Presentation: A 58-year-old female with hypertension and end stage renal disease (ESRD) on hemodialysis was admitted with subacute dyspnea accompanied by abdominal pain and swelling. During a previous admission for similar symptoms three months prior, CT of the abdomen and pelvis revealed ascites and an adnexal mass measuring 8.6×5.2 cm. She was treated for hypertensive emergency and pulmonary edema and discharged with a referral to gynecological oncology. Due to concern for Meigs syndrome, she underwent paracentesis with removal of 1750 ml of ascitic fluid. Cytology was negative for malignant cells and no other studies were sent. She subsequently underwent robotic assisted hysterectomy and bilateral salpingectomy five weeks prior to the current hospitalization. Surgical pathology demonstrated a serous cystadenoma, leading to a final diagnosis of pseudo-Meigs syndrome. Following surgery, she gradually noted swelling of her abdomen and legs despite regular hemodialysis, prompting the current admission. Initial work-up demonstrated coarsened hepatic parenchymal echogenicity on ultrasound, resolved hepatitis B infection, and otherwise unremarkable infectious, autoimmune, and inflammatory studies. Diagnostic paracentesis revealed a total neutrophil count of 10 cells/microliter, with fluid protein of 4.0 g/dL, fluid albumin of 2.0 g/dL, and serum albumin of 3.4 g/dL, yielding a serum ascites albumin gradient (SAAG) of 1.4. Echocardiography demonstrated a normal left ventricular ejection fraction of 65% with grade III left ventricular diastolic dysfunction. The patient was diagnosed with acute on chronic heart failure with preserved ejection fraction complicated by cardiac ascites. She was initiated on sacubitril-valsartan with plans to begin sodium-glucose-cotransporter-2 therapy in the outpatient setting.

Discussion: Meigs syndrome is the triad of pleural effusion, ascites, and ovarian fibroma. The phenomenon can also occur with other types of benign ovarian tumors, in which case it is labeled as pseudo-Meigs syndrome. The pleural effusion and ascites in both syndromes resolve quickly following resection of the tumor. This case illustrates the challenge of anchoring bias. Anchoring bias refers to the practice of prioritizing information and data supporting the physician’s first impression (1). The SAAG in Meigs syndrome is typically less than 1.1, so a complete diagnostic workup for ascites – rather than the targeted work-up for a relatively rare diagnosis pursued in this case – could have significantly decreased the time to a correct diagnosis and saved the patient unnecessary surgery and hospitalizations. Even after she was admitted to a general medicine service, the prior diagnosis of pseudo-Meigs syndrome contributed to initial anchoring by the primary team and led to delays in the diagnosis and treatment of cardiac ascites despite this being the second most common cause of ascites in patients on maintenance hemodialysis (2). Clinicians who are aware of cognitive biases like anchoring can work to mitigate their effect. Techniques include questioning initial impressions, actively considering other diagnoses, and seeking data to refute the initial diagnosis.

Conclusions: Anchoring bias can affect the diagnostic workup of conditions and preclude accurate diagnosis, timely treatment, and cost-prudent patient care. Clinical contexts predisposing physicians to anchoring bias are impossible to avoid. However, being aware of cognitive biases is the first step in mitigating them.