Atraumatic chylous ascites: systematic review on symptoms and causes

Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites

We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.

Hybrid Lymphovenous Anastomosis Surgery Guided by Intraoperative Mesenteric Intranodal Lymphangiography for Refractory Nontraumatic Chylous Ascites: A Case Report

Refractory chylous ascites can cause significant nutritional and immunologic morbidity, but no clear treatment has been established. This article introduces a case of a 22-year-old female patient with an underlying lymphatic anomaly who presented with refractory chylous ascites after laparoscopic adnexectomy for ovarian teratoma which aggravated after thoracic duct embolization. Ascites (>3,000 mL/d) had to be drained via a percutaneous catheter to relieve abdominal distention and consequent dyspnea, leading to significant cachexia and weight loss. Two sessions of hybrid lymphovenous anastomosis (LVA) surgery with intraoperative mesenteric lymphangiography guidance were performed to decompress the lymphatics. The first LVA was done between inferior mesenteric vein and left para-aortic enlarged lymphatics in a side-to-side manner. The daily drainage of chylous ascites significantly decreased to 130 mL/day immediately following surgery but increased 6 days later. An additional LVA was performed between right ovarian vein and enlarged lymphatics in aortocaval area in side-to-side and end-to-side manner. The chylous ascites resolved subsequently without any complications, and the patient was discharged after 2 weeks. The patient regained weight without ascites recurrence after 22 months of follow-up. This case shares a successful experience of treating refractory chylous ascites with lymphatic anomaly through LVA, reversing the patient's life-threatening weight loss. LVA was applied with a multidisciplinary approach using intraoperative mesenteric lipiodol, and results showed the possibility of expanding its use to challenging problems in the intraperitoneal cavity.

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism

BACKGROUND

The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization.

AIM

To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA.

METHODS

This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions.

RESULTS

A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003].

CONCLUSION

Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

ABSTRACT

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.

Massive Right Chylothorax Secondary to a Severe Systemic Lupus Erythematosus Flare With Secondary Evans Syndrome: A Case Report and Literature Review

This case report describes a 23-year-old male patient who presented with right chylothorax as the initial manifestation of a severe flare of systemic lupus erythematosus (SLE) and secondary Evans syndrome. Chylothorax and chylous ascites are rare features of SLE that can occur due to the accumulation of triglyceride-rich fluid in serous cavities. However, they have never been reported as the initial manifestation of a lupus flare. Evans syndrome is a rare disease characterized by autoimmune hemolytic anemia and immune thrombocytopenia, which can be secondary to SLE. The concomitant occurrence of both chylothorax and Evans syndrome in the setting of systemic lupus erythematosus has never been described, and the exact causative mechanisms of both entities are yet to be fully understood. In this report, we discuss our approach to this challenging case to broaden the understanding of the clinical manifestations of systemic lupus erythematosus. Our findings emphasize the importance of considering rare features of systemic lupus erythematosus and secondary diseases when evaluating patients with the disease.

Chylous ascites as a rare complication of abdominal trauma in a 7-year-old girl: A case report

Key Clinical Message

Abdominal trauma can be one of the causes of chylous ascites in pediatric cases, along with tuberculosis and malignancy. However, a definitive diagnosis is more reasonable to be done by excluding other causes.

Abstract

Chylous ascites (CA) is a rare type of ascites. Though it has high mortality and morbidity rates, which usually happen due to the rupture of lymph vessels into the peritoneal cavity. Congenital abnormalities, including lymphatic hypoplasia or dysplasia, are the most causes in pediatrics. CA following trauma in children is very rare, and to the best of our knowledge, there are very few reports in this regard. Here, we report a 7-year-old girl who was referred to our center with CA after a car accident.

Chylothorax and chylous ascites: Overview, management, and nutrition

Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.

Acute Chylous Ascites Status Post Median Arcuate Ligament Syndrome Decompression: A Unique Case Report and Literature Review

Chylous ascites (CA) are a rare finding of triglyceride-rich peritoneal fluid within the abdominal cavity. Malignancy, cirrhosis, and trauma after abdominal surgery are the leading causes of CA in adults. Currently, there are no published guidelines on the management of CA. This report describes a case of an 18-year-old female presenting with abdominal pain and distention following median arcuate ligament syndrome (MALS) decompression. A computed tomography (CT) of the abdomen and pelvis showed large-volume ascites with normal hepatic morphology. Paracentesis and ascitic fluid studies were positive for milky fluid rich in triglyceride. Her recent history of MALS decompression revealed the cause of her acute CA to be a postoperative complication from her abdominal surgery. This case highlights the diverse etiology of ascites and the importance of a careful history and physical examination when evaluating adults with ascites.

Left-Sided Transudative Chylothorax With Concomitant Chylous Ascites in the Setting of Liver Cirrhosis

Most chylothoraces are caused by trauma and malignancy, and pleural fluid analysis typically demonstrates an exudative effusion. Transudative chylothorax is a rare manifestation and has only been cited in case reports in the current literature. Here, we present the case of a 59-year-old male with a history of liver cirrhosis secondary to alcohol abuse, chronic kidney disease stage 3a, and hypertension who presented with a left-sided pleural effusion and abdominal ascites. A thoracentesis and abdominal paracentesis were performed, and fluid analyses demonstrated a transudative chylothorax with concomitant chylous ascites. In this review, we aim to highlight a rare case of transudative chylothorax and discuss the pathogenesis and management of this condition.

Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

How we approach pediatric congenital chylous effusions and ascites

Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.

Management of chylous ascites with surgery and frusemide in a new born

Chylous ascites is the accumulation of milky fat-rich chyle in the peritoneal cavity. It is a rare condition in children. Congenital malformations of the lymphatic vascular channel are the predominant cause in children. Diagnosis is often confirmed by paracentesis of the chylous ascitic fluid. Treatment is generally conservative except in rare refractory cases that surgery is required for closure of the leak site or excision of the lymphatic cyst. Here is a report on the management of chylous ascites in a 6-h-old girl presenting in acute respiratory distress with acute abdominal distention due rapid increase in chylous ascitic fluid volume that was managed with surgery and frusemide.

Chylous ascites with lymphatic leakage localization: technical aspects and clinical applications

BACKGROUND

Carbon nanoparticle suspension (CNS) was applied to locate the lymphatic leakage in chylous ascites (CA). However, the flow speed and distance of the CNS were particularly decreased in the following two cases (patient 5 and 6). This study aimed to investigate and improve the flow speed and distance of the CNS via a rat model.

METHODS

Seven patients with CA were accepted for surgery in the past two years. Clinical data were recorded. Rats were divided into two groups to confirm the hypothesis regarding whether accepting milk or orally administered food before surgery was the key factor in CA surgery with CNS. The animals were divided into 2 groups: experimental group of 5 rats receiving fat emulsion injection (2 g/kg) 30 min before the operation and control group of 5 rats receiving saline. We analyzed flow speed and distance of the CNS in two groups of rats. The hypothesis established was that CNS movements pattern differ depending on the degree of capillary lymph duct filling. Finally, the late case reconfirmed the hypothesis again.

RESULTS

In animal experiments, the CNS in the preoperative high-fat feeding group moved faster and over a longer distance than that in the control group (0.51 ± 0.09 cm vs. 0.19 ± 0.10 cm, respectively; p < 0.05). Based on this, the CNS was applied to the seventh patient, who had been given a diet with a slightly higher fat content 3 days before the operation, and marked improvement with a complete cure was recorded.

CONCLUSIONS

The capillary lymph duct was beginning to swell after dietary intake. The dilation of the lymph vessel could make it easier for the CNS to move and reach the leakage.

Sit-ups and emergency abdominal surgery: a rare case of intestinal volvulus and resultant chylous ascites incited by abdominal exercises

Chylous ascites is a unique phenomenon defined in the literature by ascitic fluid with a triglyceride content &gt;200 mg/dl. This rather rare entity can be associated with a number of different pathologies related to abnormalities within the lymphatic system. This case report serves to demonstrate an intestinal volvulus and resultant chylous ascites found on exploratory laparotomy in an otherwise healthy individual who participated in routine, extreme abdominal exercises.

Gut and liver involvement in pediatric hematolymphoid malignancies

Hematolymphoid malignancies are common neoplasms in childhood. The involvement of the gastrointestinal (GI) tract, liver, biliary system, pancreas, and peritoneum are closely interlinked and commonly encountered. In leukemias, lymphomas, and Langerhans cell histiocytosis (LCH), the manifestations result from infiltration, compression, overwhelmed immune system, and chemotherapy-induced drug toxicities. In acute leukemias, major manifestations are infiltrative hepatitis, drug induced gastritis, neutropenic typhlitis and chemotherapy related pancreatitis. Chronic leukemias are rare. Additional presentation in lymphomas is cholestasis due to infiltration or biliary obstruction by lymph nodal masses. Presence of ascites needs a thorough workup for the underlying pathophysiology that may modify the therapy and affect the outcome. Uncommon hematolymphoid malignancies are primary hepatic, hepatosplenic, and GI lymphomas which have strict definitions. In advanced diseases with extensive spread, it may be impossible to distinguish these diseases from the primary site of origin. LCH produces biliary strictures that mimic as sclerosing cholangitis. Liver infiltration is associated with poor liver recovery even after chemotherapy. The heterogeneity of gut and liver manifestations in hematolymphoid malignancies has a clinical impact on their management. Though chemotherapy is the mainstay of therapy in all hematolymphoid malignancies, debulking surgery and radiotherapy have an adjuvant role in specific clinical scenarios. Rare situations presenting as liver failure or end-stage liver disease require liver transplantation. At their initial presentation to a primary care physician, given the ambiguity in clinical manifestations and the prognostic difference with time-bound management, it is vital to recognize them early for optimal outcomes. Pooled data from robust registries across the world is required for better understanding of these complications.

Chylous ascites in a case of henoch-schonlein purpura - A case report and literature review

Chylous ascites is a rare form of ascites characterized by the accumulation of lymph fluid in the peritoneal cavity. Henoch-Schonlein purpura (HSP) is a form of vasculitis usually seen in children affecting small vessels. Gastrointestinal (GI) manifestations of HSP are coming to the forefront as a presenting symptom. The presence of a rash usually succeeds the GI manifestations, making diagnosis difficult and leading to unnecessary surgical interventions. Our case shows a 38-year-old female who presented with an acute abdomen followed by an erythematous rash noticed later on, with radiological investigations suggestive of acute appendicitis. Chylous ascites was found as an incidental finding on diagnostic laparoscopy with a healthy appendix.

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

BACKGROUND

Mycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare.

CASE PRESENTATION

A 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient's general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30.

CONCLUSIONS

We report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.

Chylous ascites as a marker for intestinal viability in a small bowel obstruction: a case report

Chylous ascites (CA) is the uncommon extravasation of triglyceride-rich fluid into the abdominal cavity as a result of the disruption of the abdominal lymphatic system. A patient who had previously undergone a subtotal colectomy presented with a closed-loop small bowel obstruction (SBO), underwent an emergency laparotomy with adhesiolysis and had intra-operative findings of milky intra-abdominal free fluid confirmed on analysis as CA. His post-operative period was complicated by a prolonged ileus, and following resolution, he was subsequently discharged home. Here, we present a case of a closed-loop SBO in which CA may be an indicator of intestinal viability.

Chylous Ascites, Unusual Association with Ductal Pancreatic Adenocarcinoma with Plasmacytoid Morphology: A Case Report and Literature Review

Chylous ascites represents a relatively uncommon condition. In this paper, we present a case of chyloperitoneum associated with pancreatic ductal adenocarcinoma (PDAC) and a review of literature regarding chylous ascites. A 76-year-old male patient was admitted in emergency department with acute abdomen. A pancreatic cancer was suspected. Subtotal spleno-pancreatectomy, for a nodular mass infiltrating the mild and distal portion of the pancreas, was necessary. During surgical intervention in the peritoneal cavity, a moderate quantity of whitish and thick consistency fluid with milk-like appearance was observed to be accumulated. After examination of the fluid, chyloperitoneum was diagnosed. The histologic examination showed a PDAC, with multiple emboli in lymph vessels, with tumor cells with plasmacytoid morphology, diagnosed as lymphangiosis carcinomatosa. The patient died at 3 weeks after surgical intervention. In patients with pancreatic cancer and chylous ascites, suspicion of tumor-related blockage of the lymphatic flow should be suspected. Prognosis of PDAC should be evaluated not only based on the number of lymph node metastases, but also considering the number of lymph vessels with tumor emboli and the architecture of tumor cells. This is the first reported case of a PDAC with plasmacytoid morphology of lymphangiosis carcinomatosa.

Chyloperitoneum as the Initial Manifestation of Gastrointestinal Neoplasia

Chyloperitoneum is defined as the presence of lymph within the peritoneal cavity, resulting from obstruction or injury of lymph ducts, mostly at the level of the gastrointestinal tract. This can occur in the context of congenital diseases, traumas, infections, neoplasms, hepatic disease, heart disease, and postoperative complications. The most common symptoms described are abdominal distention and mild pain in a course of weeks to months, with dyspnea, peritonitis, and in a few cases weight gain is observed due to the high intra-abdominal pressure. We present a case of a 56-year-old male with no significant personal history, who has a clinical picture of approximately three months of evolution, consisting in sensation of an abdominal mass predominantly in the left hemiabdomen, associated with progressive abdominal distension, changes in intestinal habit, lower limb edema, dyspepsia, occasional postprandial emesis, and unintentional weight loss of 20 kg. In non-traumatic conditions, the most frequent cause of chylous ascites is a malignancy disease followed by cirrhosis and mycobacterial infections. Taking into consideration that adenocarcinoma is the most frequently reported histologic subtype of jejunum neoplasm, and that not all cases of lymphoma debut with chylous ascites, it can be concluded that the proportion of patients that present with this condition is exceptionally low. Chyloperitoneum is an infrequent finding, having the higher detection rate in lymphatic alterations and malignancies of gastrointestinal location, in which some of the most commonly neoplasms associated with this complication are lymphoma, neuroendocrine tumors, sarcomas, and leukemia.

Strawberry milky-white blood donor's plasma: signaling uncontrolled diabetic lipemia

Intake of a fatty meal before donating blood can lead to an increased level of plasma triglyceride concentration for several hours. This may cause either turbid and or "milky-white" appearance of their venous plasma samples. We, however, report a peculiar case about a male blood donor from India, whose plasma appeared to be "strawberry milky-white" in colour. On inquiry, he gave a history of poorly controlled diabetes mellitus type-II. Further, this was affirmed by his high blood glucose concentration [nearly 326mg/dL] and HbA1c [13.7%] respectively. Moreover, his plasma triglyceride concentration was elevated up to 376mg/dL. His treatment was started at our hospital and the strawberry colour of his plasma, dramatically recovered to normal straw-colour after achieving a fairly good glycemic control with the insulin therapy.

Management of intractable post-adrenalectomy chylous ascites with microsurgical intra-abdominal lymphaticovenous anastomosis: A case report and literature review

Postoperative chylous ascites is a rare but highly morbid complication following thoracic or abdominal surgeries. Treatment options vary according to different clinical scenarios and facility equipment, but there is no standard guideline. We report a case of 46-year-old patient with chylous ascites after left laparoscopic adrenalectomy for metastatic lung cancer. The conservative treatments failed, included diet control, somatostatin provided and intranodal lymphangiography with lipiodol injection. Laparotomy was performed to explore the lymphatic vessel in the retroperitoneal area where a major and several small leaking holes were identified along the thoracic duct. The left gonadal vein was explored and transposed toward the lymphatic vessel. The lymphaticovenous anastomosis (LVA) was done using side (major leaking hole) to end (gonadal vein) fashion. The chylous leakage dropped from 2000 to 200 mL per day gradually within 10 days after LVA, and the patient was discharged uneventfully 30 days after the LVA surgery. He was followed at our clinic during the first postoperative 10 months without recurrent chylous ascites. This case demonstrates that microsurgical intervention with LVA to physiologically drain the chyle can be an optimal treatment for chylous ascites. A literature review was also conducted, and strategic management is proposed.

Lymphatic dysfunction in advanced cirrhosis: Contextual perspective and clinical implications

The lymphatic system plays a very important role in body fluid homeostasis, adaptive immunity, and the transportation of lipid and waste products. In patients with liver cirrhosis, capillary filtration markedly increases, primarily due to a rise in hydrostatic pressure, leading to enhanced production of lymph. Initially, lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation. However, the lymphatic functions become compromised with the progression of cirrhosis and, consequently, the lymphatic compensatory mechanism gets overwhelmed, contributing to the development and eventual worsening of ascites and edema. Neurohormonal changes, low-grade chronic inflammation, and compounding effects of predisposing factors such as old age, obesity, and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis. Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia, which may rupture into the intestinal lumen, resulting in the loss of protein, chylomicrons, and lymphocyte, with many clinical consequences. Rarely, due to high pressure, the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites. Despite being highly significant, lymphatic dysfunctions in cirrhosis have largely been ignored; its mechanistic pathogenesis and clinical implications have not been studied in depth. No recommendation exists for the diagnostic evaluation and therapeutic strategies, with respect to lymphatic dysfunction in patients with cirrhosis. This article discusses the perspectives and clinical implications, and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.

Idiopathic acute chylous peritonitis during pregnancy, mimicking perforated acute appendicitis: A case report

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CA is extremely rare, especially in pregnancy, previously described in the setting of pancreatitis but can present as perforated appendicitis.

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In early pregnancy there is a diagnostic dilemma and once other sources of sepsis are excluded a diagnostic laparoscopy should be considered.

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During diagnostic laparoscopy fluid should be assessed for triglycerides, microscopy/culture/cytology and a potential precipitating agent.

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Medium fatty-chain acid diet with MCT oil supplementation and dietician input is crucial in management.

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Unclear role of antibiotics, on the balance of risk benefit it was deemed appropriate to administer antibiotics.

Introduction and importance

Chylous ascites (CA) is an extremely rare presentation in pregnancy and poses a diagnostic challenge in clinical practice. There have only been a few case reports of CA in pregnancy with the majority of cases found incidentally at the time of caesarean section or in the context of pancreatitis.

Case presentation

A 36-year-old female who was 13 weeks pregnant had clinically presented right iliac fossa pain with peritonitis and had signs of sepsis. Once other potential sources of sepsis were excluded, had proceeded to diagnostic laparoscopy performed by the treating consultant given there were no appropriate out-of-hours imaging modalities available.

Clinical discussion

This case report hopes to advocate for the effective intervention of a diagnostic laparoscopy in this setting and other important considerations for management during first trimester pregnancy. Upon diagnosis the patient was put onto a medium chain fatty acid diet with excellent outcomes post operatively and at the outpatient follow up. The case report has been reported in line with the SCARE 2020 criteria [11].

Conclusion

Chylous ascites is a rare finding and additionally is even more rare to cause peritonism. What we found most interesting in this case is that in the absence of any other potential sources of infection, how chylous ascites not only presented with peritonism but prompted a septic response. Another pertinent issue is that in pregnancy we are limited with investigative options and therefore diagnosis will depend on the clinical presentation and decision for prompt diagnostic/therapeutic laparoscopy should be strongly considered.

Unusual presentation of a man with recurrent chylous ascites

We describe an interesting case of a 77-year-old man presenting with refractory chylous ascites of unknown aetiology. After extensive diagnostic workup, unifying diagnosis of an intriguing condition of yellow nail syndrome was reached. This case is unusual as it describes a rare cause of chylous ascites in this age group. Despite refractory ascites and the need for recurrent paracentesis, this patient has a good prognosis with no significant impact on overall mortality.

Disseminated Mycobacterium avium Infection Complicated with Chylous Ascites in a Patient with Neutralizing Autoantibodies to Interferon-γ

A 68-year-old man visited our hospital due to anorexia, weight loss and a fever. We diagnosed the patient with disseminated Mycobacterium avium complex (MAC) and confirmed the presence of interferon (IFN)-γ neutralizing autoantibodies (IFN-γAb). His lesions improved following antibiotic therapy, but chylous ascites (CA) developed seven months after treatment. CA was able to be controlled by subcutaneous octreotide and diet therapy. IFN-γAb is recognized as having a critical role in the pathogenesis of disseminated MAC disease, but its clinical features are not fully understood. CA may be a complication that develops during the treatment of disseminated MAC infection.

Complete resolution of acute pancreatitis-induced chylous ascites following transhepatic portal vein stenting

We introduce a case of a 73-year-old man who developed intractable chylous ascites due to portal vein compression as a result of peripancreatic inflammatory changes after acute biliary pancreatitis. After stenting the portal vein stenosis, the chylous ascites improved from requiring weekly paracentesis to requiring no drainage within 4 months of the procedure and at the 15-month follow-up. To our knowledge, it is the first case reported in the literature where portal vein stenting has successfully been used to treat pancreatitis-induced chylous ascites.

Refractory Congenital Chylous Ascites: Role of Fibrin Glue in its Management

Chylous ascites is the accumulation of triglyceride-rich lymph in the abdomen. Its occurrence during the infantile period is quite rare. Congenital chylous ascites (CCA) is one, which occurs in children <3 months of age, due to maldevelopment of the lymphatic system. There is no clearly defined treatment protocol for CCA; however, the use of medium-chain triglycerides (MCT)-based diet or total parenteral nutrition (TPN) with octreotide has been successful. Failure of conservative management, however, leads to surgical exploration to deal with those leaking lymphatics. In our case, we had initially given a trial of managing the child with MCT-based diet followed by a TPN along with octreotide. However, the failure of both leads us to operate the child during which we incorporated the use of fibrin glue over the leaking mesenteric lymphatic vesicles, which ultimately led to the resolution of the chylous ascites.

Deciphering the reasons for milky-white blood donor plasma

Donors who eat a fatty meal before donating blood are known to have an increased level of plasma triglyceride concentrations for several hours. This may contribute to "milky-white" appearance of their plasma samples. We herein report the case of a blood donor who gave a history of the intake of a fatty meal, on the night prior to donation. This was affirmed by his serum lipid concentration done on the following day and on repeating the same subsequently after two weeks of donation respectively.

Chylous Ascites and Lymphoceles: Evaluation and Interventions

Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.

Novel technique to manage refractory chylous ascites with carbon nanoparticle suspension in infants

OBJECTIVE

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. In infants, CA is mostly caused by lymphatic malformation or unknown reasons. The creation of a shunt for the lymphorrhea is the last option for patients unresponsive to all other conservative treatments. Localization of the leakage is a critical problem during surgery. We applied a carbon nanoparticle suspension (CNS) in CA patients to locate the external lymphatic leakage and evaluated its utility during surgery.

PATIENTS AND METHODS

Twelve infants with CA were treated in our center recently. Ten patients received laparotomy, one refused therapy, and one was cured after undergoing conservative treatment. Recently, two infants with CA received CNS in the visceral peritoneum during laparotomy. The results of the traditional procedure were compared to our innovative technique for CA to evaluate the use of CNS in treating CA.

RESULTS

The features of the baseline data did not differ substantially. Location of the leakage with CNS was employed in 2 of the 10 patients whose lymphatic leakages were identified with the resolution of the refractory CA. Overall, in 5 patients, ascites was resolved successfully. The refractory CA was resolved more effectively in patients in whom the leakage site was identified with CNS than in patients in whom the leakage site could not be identified under conventional surgery.

CONCLUSIONS

Injecting CNS improved the accuracy of lymphorrhagia leakage site identification and the outcomes of infants who underwent surgical treatment for refractory CA.

LEVEL OF EVIDENCE

II-III.

Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.

White mesentery and chylous ascites: an interesting presentation of mesenteric lymphangioma

We present an interesting and unusual case of a 57-year-old woman presenting with symptoms concerning for a bowel obstruction, and diagnostic imaging concerning for an internal hernia. The patient underwent an emergency laparotomy and was found to have chylous ascites throughout the abdomen, and the extravasation of chyle into the mesentery giving an appearance of a white mesentery. During this case, we will present all of the findings and discuss the unusual underlying pathology.

An Unusual Combination of Three Rare Complications: Pleuro-Pancreatic Fistula, Chylous Ascites, and Renal Vein Thrombosis, in a Case of Acute Severe Pancreatitis

Background  Acute pancreatitis is fraught with a variety of complications, which account for the mortality associated. Our case had a fulminant course, with three rare, near-fatal complications and was successfully managed conservatively. Pleural effusion due to pleuro-pancreatic fistula is uncommon, seen in only 1% cases, of which right-sided effusions are rarer still. Management modalities include conservative, endoscopic, and surgical options. Chylous ascites is an extremely rare complication of pancreatitis and is managed with high protein, low lipid diet, restricted to medium-chain triglycerides (MCTs). Extra-splanchnic venous thrombosis is uncommon in pancreatitis, and isolated renal vein thrombosis is very rare.

Case Presentation  A 34-year-old, chronic alcoholic male, presented to the outpatient department (OPD) in a state of shock and respiratory distress. Chest radiograph showed massive right-sided pleural effusion. The pleural fluid was hemorrhagic with markedly elevated amylase levels, and contrast-enhanced computed tomography (CECT) confirmed the presence of a right-sided pleuro-pancreatic fistula. Left renal vein thrombosis was also noted. The patient improved with chest drain, intravenous (IV) octreotide, and anticoagulants. Subsequently, he developed hemorrhagic pancreatic ascites, which later turned chylous. This was managed with dietary modifications. The patient had a prolonged recovery but was finally discharged after 45 days.

Conclusion  It is a challenge managing the various complications of acute severe pancreatitis. We describe this case to emphasize maintaining a high sensitivity for timely diagnosis and appropriate addressal of all the complications for better patient outcomes.

First Case of Chylous Ascites after Laparoscopic Myomectomy: A Case Report with a Literature Review

Introduction: Chylous ascites is a rare form of ascites characterized by milk-like peritoneal fluid, rich in triglycerides. Clinical signs and symptoms include abdominal distention, pain, nausea, and vomiting. In gynecology, the most common cause for its occurrence is lymph dissection leading to impairment of major lymphatic vessels. There are only a few reported cases of chylous ascites arising after operations for benign diseases. Case report: We report a case of a 46-year-old female patient, who underwent laparoscopy for a myomatous node with chylous ascites occurring on post-surgery Day 2. The ascites was conservatively managed. The exact cause of the chyloperitonitis could not be determined. Conclusion: Although extremely rarely, chylous ascites may also occur in operative interventions for benign diseases in gynecological surgery.

Management of postoperative chylous ascites after surgery for ovarian cancer: a single-institution experience

Postoperative chylous ascites is a rare complication from operative trauma to the cisterna chyli or lymphatic vessels in the retroperitoneum. In the present study, we aimed to identify the incidence of postoperative chylous ascites in patients treated for ovarian cancer and to describe its management. We retrospectively reviewed all patients submitted to surgery for ovarian cancer at our Institution from October 2016 to November 2018. We analyzed the clinicopathological features, including the primary tumor histology, stage, grade, surgical procedure, median number of harvested pelvic and para-aortic lymph nodes. We described our experience in the diagnosis and management of chylous ascites. Five hundred and forty-six patients were submitted to surgery for ovarian cancer and 298 patients received pelvic and/or para-aortic lymphadenectomy. Chylous ascites occurred in 8 patients with an incidence of 1.4% in the overall population and a 2.68% among patients receiving lymphadenectomy. All patients received total parenteral nutrition (TPN) with Olimel N4E 2000 mL (Baxter^®) and somatostatin therapy with 0.2 mL per 3 times/day for a median of 9 days (range 7-11). Median hospital stay was 15 days (range 7-16). All patients were successfully managed conservatively and none required surgical correction. Conservative management of chylous ascites with TPN, somatostatin and paracentisis is feasible and effective. These data should be confirmed by prospective multicentric studies.

Calcium Channel Blocker-Associated Chyloperitoneum in Patients Receiving Peritoneal Dialysis: A Systematic Review

Unlike chyloperitoneum associated with clinical conditions including cancer, cirrhosis, and traumatic surgery, calcium channel blocker (CCB)-associated chyloperitoneum is rarely discussed in comprehensive studies on chyloperitoneum. We aimed to investigate the prevalence and characteristics of CCB-associated chyloperitoneum in peritoneal dialysis (PD) patients. The MEDLINE, Embase, CENTRAL, CiNii, and RISS databases were systematically searched for clinical studies on CCB-associated chyloperitoneum in PD patients published up to 31 July 2018. A total of 17 studies (four cohort studies, one case series, and 12 case reports) were selected. Eight CCBs, namely amlodipine, benidipine, diltiazem, lercanidipine, manidipine, nifedipine, nisoldipine, and verapamil, were reported to be associated with chyloperitoneum; manidipine and lercanidipine were the most frequently reported. The average prevalence of chyloperitoneum for lercanidipine was 25.97% in three cohort studies, two of which had a moderate or high risk of bias. Most of the studies revealed chyloperitoneum development within 4 days of initiation of CCB therapy and chyloperitoneum disappearance within 24 h of CCB withdrawal. The results of this study emphasise on the need for awareness among healthcare professionals regarding CCB-associated chyloperitoneum in PD patients. Further studies elucidating the causality and clinical implication of CCB-associated chyloperitoneum are needed.

Calcium Channel Blocker-Related Chylous Ascites: A Systematic Review and Meta-Analysis

BACKGROUND

Chylous ascites is an uncommon condition characterized by a white, milky-appearing peritoneal fluid, and is related to disruption of the lymphatic system from any cause. There have been very few previous reports of calcium channel blockers (CCBs) as potential causes of chylous ascites, and most of the patients were undergoing peritoneal dialysis.

AIMS

To review the pathogenesis, clinical manifestations, laboratory examinations, treatment options, and prognosis of patients with CCB-related chylous ascites.

METHOD

A retrospective analysis was conducted for patients with CCB-related chylous ascites from publications in PubMed, EMBASE, and LILACS between January 1993 and December 2018.

RESULTS

A total of 48 cases were included. The average age at disease onset was 50.2 ± 10.9 years, with a male:female ratio of 1.5:1.0. The symptoms of abdominal distension/pain and chylous ascites were observed within 48⁻72 h of drug initiation and disappeared within 24 h of drug withdrawal. Rechallenge was performed in 10 patients, and all (100%) of them showed chylous effluents that disappeared within 24 h after stopping drug treatment.

CONCLUSIONS

To summarize, CCB-related chylous ascites is formed of white, milky ascites/effluents that appear after administration of CCBs. Physicians must be aware of the possibility of chylous ascites when administering CCBs, particularly in patients with renal function impairment or patients with end-stage renal disease who are undergoing peritoneal dialysis.

Peritoneal lymphoma with ascites mimicking portal hypertensive ascites: A case report

RATIONALE

Lymphoma with an initial manifestation of ascites and peritoneal invasion is rare.

PATIENT CONCERNS

A 65-year-old woman presented to the emergency department with a 3-week history of abdominal distention, anorexia, and night sweating, and a 2-week history of melena. She was a silent hepatitis B virus carrier. Abdominal ultrasound showed massive ascites without cirrhosis. Abdominal computed tomography revealed ascites, infiltrative peritoneal lesions with omental cake appearance, and lymphadenopathies.

DIAGNOSIS

We performed paracentesis and the ascites cytology was obtained. The patient also underwent esophagogastroduodenoscopy, which showed ulcerative tumors in the stomach. Both ascites cytology and pathology of the gastric tumors confirmed the diagnosis of B-cell lymphoma.

INTERVENTIONS

This patient received 7 cycles of chemotherapy.

OUTCOMES

Follow-up imaging studies revealed partial remission of lymphoma, but an enlargement of residual tumors in omentum and mesentery, which resulted in intractable ascites and rapid deterioration of performance status. Despite a change of regimen of chemotherapy, this patient expired 10 months after diagnosis.

LESSONS

Lymphoma should be one of the differential diagnoses in patients with intractable ascites not attributable to other comorbidities.

Chylous ascites and podocytopathy as the presentation of childhood lupus-an unusual occurrence

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can affect virtually any organ. Chylous ascites as a presenting manifestation of SLE has been described in a handful of cases in adults. However, to the best of our knowledge this presentation has never been reported in the pediatric age group. Podocytopathy in SLE was initially considered to be a chance association. However, more recently it has been suggested that minimal change disease is not only a chance association; it is part of the lupus nephritis spectrum.