A white woman in her 60s with undifferentiated connective tissue disease and long-standing pulmonary arterial hypertension presented for evaluation of new-onset ascites. The patient reported no alcohol or drug use and no personal or family history of liver disease. Medications included diltiazem and furosemide. On physical examination, her blood pressure was 108/54 mm Hg and pulse was 64/min. She was anicteric with mild bilateral temporal wasting and jugular venous distension. Further pertinent findings included regular heart rate and rhythm with an accentuated P2, grade 1/6 holosystolic murmur in the left lower sternal border, full bulging abdomen with flank dullness, and scattered spider angiomata on her chest. Doppler ultrasound revealed an irregular liver echo pattern without lesions, normal common bile duct, patent portal and hepatic vasculature, splenomegaly, and ascites. Laboratory results including diagnostic paracentesis are shown in Table 1.