History: A 19-year-old white man presented to the emergency department with a 1-week history of epigastric abdominal pain, nausea, vomiting, diarrhea, and swelling of his legs and scrotum. He had a history of gastroesophageal reflux disease that was treated with a proton pump inhibitor. On chest radiographs and abdominal ultrasonographic (US) images, bilateral pleural effusions and ascites were seen. Results of routine blood analysis revealed hypoproteinemia; the protein level was 3.2 g/dL, with an albumin level of 1.6 .g/dL. A stool study revealed that the a1-antitryp-sin level was elevated, at 564 mg/dL.The patient underwent esophagogastroduodenoscopy, which was followed by abdominal computed tomography (CT) and upper gastrointestinal fluoroscopy.