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.

Rare Combination of Chyloperitoneum Secondary to Primary Small-Bowel Volvulus

Chylous ascites is the exudation from lymphatic content to the peritoneum and is a rare situation that mostly occurs following medical causes like neoplasms or cirrhosis. However, trauma to the lymphatic system due to compression by masses or altered anatomy can be a trigger too. We describe a rare combination of a primary small bowel volvulus in a young healthy adult causing chylous ascites. Obstruction caused by a primary small bowell volvulus can re-arrange the lymphatics anatomy increasing their flow pressure which can lead to rupture and leak. This is an emergent scenario that needs to be addressed quickly because of bowel ischaemia. CT scan is the gold standard to expedite diagnosis and go to surgical treatment. Although it can be an impactful finding, treatment of the cause behind chylous ascites results in complete resolution without any bowel resection.

Chylous ascites as a sequelae of primary small bowel volvulus in a virgin abdomen

Chylous ascites (CA) results in a thick white ascitic fluid, akin to milk. It is most commonly caused by malignancy and cirrhosis in adults. Here we present only the second reported case of primary small bowel volvulus resulting in CA in the virgin abdomen. The patient presented with acute onset, severe abdominal pain. She underwent an urgent laparotomy where a large volume of CA was drained. The bowel and its mesentery were congested with chyle and stained white. Following detorsion the bowel returned to normal, and the patient recovered well. Here we review the radiological findings and aetiology of CA, due to small bowel volvulus. This case highlights the importance of timely surgical intervention in patients with volvulus to prevent irreversible bowel ischaemia and if untreated, perforation.

Intestinal malrotation causing chylous ascites in an adolescent: a case report

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Chylous ascites due to intestinal malrotation is a rare occurrence, especially in adolescent and adult patients.

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Chylous ascites due to intestinal malrotation typically occurs early in life with painless distension of the abdomen.

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Our case is a male adolescent who presented with abdominal pain and a history of congenital hernia repair.

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Ladd’s procedure was successfully performed in our case with no complications.

Introduction

Intestinal malrotation is a rare etiology of chylous ascites in adolescents. Chylous ascites is caused by lymphatic system disarrangement, which can result in an anomalous build-up of a lymphatic fluid rich in lipid, namely chyle in the peritoneal cavity.

Presentation of case

We present a case of a 16-year-old Saudi Arabian male who came to the emergency department with right upper quadrant pain associated with difficulty in passing stool for one day and a history of congenital diaphragmatic hernia (CDH) repair at the age of 4 months. Free fluid in the abdomen was noticed in the bedside ultrasound. Abdominopelvic computed tomography revealed dilated small bowel loops and a whirl sign of the mesentery, which indicated intestinal torsion. The patient was treated using Ladd’s procedure, and a large volume of chylous fluid was removed from the abdomen. Postoperatively, the abdominal drain revealed no chyle, and the patient was followed-up as an outpatient at which point, he reported no abdominal pain.

Discussion

Intestinal malrotation is more commonly reported in children and associated with congenital chylous ascites. Chylous ascites by itself is a rare occurrence, and very few cases attribute it to intestinal malrotation in adults. Surgical management with Ladd’s procedure is a well-documented surgery in pediatric patients, and yet it was successfully performed in our adolescent patient.

Conclusion

Surgical management of chylous ascites secondary to intestinal malrotation in an adolescent, which is considered novel in this age group, including peritoneal lavage of chyle, resulted in favorable outcomes.

Congenital chylous ascites in infants: another presentation of intestinal malrotation

OBJECTIVE

The cause of the chylous ascites in infants isn't completely clear. The purpose of this study is to discuss our experience of recognition of intestinal malrotation as a cause of congenital chylous ascites in infants.

METHODS

Medical information of 10 infants with chylous ascites, who were admitted to the hospital between 2001 and 2014, was retrospective analyzed. Preoperatively, all patients underwent a period of conservative treatment.

RESULTS

We found that nine of ten patients with intestinal malrotation, six of them underwent laparoscopic Ladd's procedure and three patients underwent open Ladd's procedure. The remaining one patient suffered from mesenteric lymph nodes rupture and laparoscopic resection was performed. The cylous ascites subsided in all patients after the surgery and no significant recurrence was encountered during follow-up time.

CONCLUSIONS

Our study demonstrates that congenital chylous ascites could be caused by intestinal malrotation, causing the obstruction of the lymphatic flow in the mesenteric lymphatic channels. Ladd's procedure maybe a safe and effective treatment for infantile intractable chylous ascites.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Primary Volvulus of the Small Intestine Exhibiting Chylous Ascites: A Case Report

BACKGROUND

Primary volvulus of the small intestine associated with chylous ascites is very rare, with only four reported cases. In this paper, we report a new case of primary volvulus associated with chylous ascites.

CASE PRESENTATION

The patient was a 70-year-old man. After experiencing bloating and abdominal pain for several hours, he called an ambulance and underwent an emergency examination at our hospital. Abdominal distension, pressure pain, and rebound tenderness were observed throughout his entire abdomen. The patient had a history of hypertension for which he was receiving oral treatment. Abdominal contrast-enhanced computed tomography (CT) revealed an edematous change in the intestinal membrane and volvulus of the small intestine. As findings suggestive of ischemia were observed in part of the intestines, emergency surgery was performed on the day of admission. Open surgery revealed approximately 500 mL of chylous ascites in the abdominal cavity. The small intestine had twisted 180° in a counter-clockwise direction at the root of the superior mesenteric artery, and the mesentery appeared milky white with edematous changes extending 75 to 240 cm from the ligament of Treitz. There was no evidence of intestinal necrosis; therefore intestinal resection was not performed. The volvulus of the small intestine was corrected. Moreover, because there was no other underlying disease observed, surgery was completed. The ascites collected during surgery revealed high levels of triglycerides at 332 mg/dL, and chylous ascites was diagnosed. An abdominal CT performed on the third day after surgery showed an improvement in intestinal edema, and primary volvulus of the small intestine associated with chylous ascites was diagnosed. Postoperative progress was good, and the patient was discharged on hospital day 10.

Chylous ascites associated with intestinal obstruction from volvulus due to Petersen's hernia: report of a case

Background

Chylous ascites is an uncommon finding which is usually associated with recent abdominal/oncologic or retroperitoneal surgery. It is not usually seen in cases of acute obstruction.

Case presentation

A patient who had previously undergone a laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction for early gastric cancer presented with acute abdominal pain and epigastric fullness. Computed tomography suggested small bowel obstruction due to volvulus. We were able to reduce the volvulus and close a Petersen’s hernia without resecting the bowel; a large amount of chylous ascites was an incidental finding.

Conclusions

We present a case of chylous ascites occurring in a setting of small bowel obstruction due to Petersen’s hernia, 3 years after successful distal gastrectomy for early gastric cancer, with no evidence of tumor recurrence.

Left paraduodenal hernia accompanying chylous ascites

Paraduodenal hernia is by far the most common form of congenital internal hernia. Chylous ascites is an accumulation of lymphatic fluid in the peritoneal cavity. It develops when the lymphatic system is disrupted due to traumatic injury or obstruction. A 40-year-old, woman showed up to the Emergency Department with severe, colicky abdominal pain. Tenderness and rebound tenderness were observed at the left abdomen. Abdominal CT confirmed a cluster of dilated proximal small bowel loops with ischemic change, without ascites. The patient underwent an emergency surgery to relieve bowel ischemia. As soon as the peritoneum was exposed, 1.5 L of chylous fluid was found. A hernial sac was found along the posterior side of the mesentery of the inferior mesenteric artery. We resected the hernial sac and pulled out the herniated small bowel. On the sixth day after the surgery, she was discharged without any complication.

Spontaneous chylous ascites, chylomediastinum and bilateral chylothoraces encountered during laparoscopic incarcerated paraesophageal hernia repair

Chylous ascites is an accumulation of milky lipid-rich lymph in the peritoneal cavity. Spontaneous chyle leak is a rare occurrence, often associated with malignancy or cirrhosis. This is a report of spontaneous chylous ascites, chylomediastinum and chylothoraces encountered in the setting of an incarcerated paraesophageal hernia. A 60-year-old female presented to the emergency department with epigastric pain, dysphagia and vomiting. Clinical presentation and imaging were concerning for an incarcerated paraesophageal hernia, and the patient was taken to the operating room. During laparoscopic reduction of the hernia and repair, chyle was encountered in the peritoneal cavity, mediastinum and pleural spaces. Postoperatively, the chyle leak resolved with a nonfat diet. The unusual occurrence of a chyle leak in this case may have been due to compression of the thoracic duct within the chest by the incarcerated paraesophageal hernia.