eng Science and Education Publishing American Journal of Medical Case Reports 2374-216X 2016-12-30 4 12 389 392 10.12691/ajmcr-4-12-5 AJMCR20164125 article Takanobu Hirosawa 1 Kazuhito Hirata kheart911@yahoo.co.jp 1 Wake Minoru 2 Division of Internal Medicine, Okinawa Chubu Hospital, 281 Miyazato, Uruma, Okinawa, Japan Division of Cardiology, Okinawa Chubu Hospital, 281 Miyazato, Uruma, Okinawa, Japan A 65-year-old woman, with past history of mitral valve replacement, developed severe right heart failure. In addition to elevated right heart pressure, she had significant hypoalbuminemia as the important cause of refractory edema. Technetium-99m-labelled human serum albumin scintigraphy showed leak of protein from the transverse colon and the excretion of alpha 1 antitrypsin in the stool was markedly increased. Diagnosis of protein losing enteropathy was established. The etiology was increased lymphatic pressure secondary to right heart failure of multifactorial cause, including elevated left side filling pressures and out of proportion pulmonary hypertension due to old tuberculosis, resulting in significant tricuspid regurgitation. The patient was managed conservatively with increased dose of furosemide from 10-20mg every other day up to 40-60mg/day, and maximum dose of tolvaptan (a vasopressin 2 receptor blocker) of 15mg/ day, in addition to high protein diet. http://pubs.sciepub.com/ajmcr/4/12/5/ajmcr-4-12-5.pdf protein losing enteropathy right heart failure tolvaptan