Mrs. J.P. is a 50-year-old woman with a long-standing history of reflux disease, emphysema, chronic iron deficiency anemia and hypothyroidism. She was referred for ongoing symptoms of fatigue, mild hepatic dysfunction and ongoing leg swelling.

She’s been experiencing symptoms of intermittent epigastric pain and tiredness over the past few years. These symptoms were already investigated once in the past. She underwent gastroscopies and colonoscopies, and was diagnosed with reflux disease. She also had various abdominal ultrasounds and CT scans of the abdomen over the years and all were unremarkable save for fatty liver. There was no history of jaundice or hepatitis but she recalled receiving a a blood transfusion in 1995. She’s also had ongoing ankle swelling for the past few years.

She denies symptoms of heartburn, reflux, nausea or vomiting. She has occasional diarrhea but no bleeding per rectum or melena. She denies symptoms of abdominal cramps or tenesmus. Her appetite has been fair and there’s been no weight loss. She reports no fever, chills or night sweats. She denies history of kidney disease or heart disease, and has no symptoms of chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea. She’s fairly active and works as a manager of a motel. She had a previous hysterectomy and hernia repair.

Her medications include levothyroxine 0.175 mg a day, esomeprazole 40 mg a day, intermittent iron supplementations (for years) and B₁₂ once a month. She quit cigarettes in 2000 after smoking for 25 years. She drinks socially in moderation.

Physical examination is essentially unremarkable for a woman of stated age and average build. She weighs 54 kilos at a height of 160 cm. Blood pressure is 112/69 mm Hg with regular rhythm. Heart sounds are normal and lungs clear. Jugular venous pressure is normal. Abdomen is soft and benign without masses or hepatomegaly. There is 1+ pitting pedal edema.

Pertinent laboratory data shows slightly elevated AST of 70 (14-36 U/L), ALT of 87 (9-52 U/L), normal GGT of 22 (8-78 U/L), slightly elevated ALP of 140 (38-126 U/L) and low albumin of 25. Hemoglobin is low normal at 124 g/L and urinalysis (twice) is negative for blood and protein. Hepatitis B serology and anti-HCV are negative. Anti-nuclear antibody and anti-mitochondrial antibodies are also negative. Anti-smooth muscle is weakly positive. Ceruloplasmin and immunoglobulin levels are normal. Serum ferritin is between 5 and 15 for the past 6 months. She had a liver biopsy because of mild, persistent elevation of transaminases and GGT and low serum albumin, but the biopsy was unremarkable.

What’s the cause of her ongoing leg swelling?