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Tri TT, Duy HP, Thuan LNA, Kiet PT, Van Khanh NH, Nhi TTY, Tran NTT, Duc NM. Gallbladder perforation following trauma in an 18-month-old child with a common bile duct cyst. Radiol Case Rep 2023; 18:4528-4532. [PMID: 37868011 PMCID: PMC10587450 DOI: 10.1016/j.radcr.2023.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Gallbladder rupture caused by blunt abdominal trauma is an uncommon injury, particularly in children. This condition occurs even less frequently in children with common bile duct cysts. The history is difficult to obtain, the clinical symptoms are indistinct, and their assessment is obscured by a slew of other lesions. Radiography cannot produce clear images. Thus, the diagnosis is frequently delayed and confirmed only during surgery. Case reports of gallbladder injury after abdominal trauma are relatively rare and there are only 50 case reports in literature for 100 years. Herein, we present the case of an 18-month-old girl who had a ruptured gallbladder funnel due to blunt abdominal trauma caused by domestic violence, with an early clinical presentation of septic shock and chylous effusion. The patient underwent surgery after being diagnosed with chylous ascites that had not responded to medical treatment. Based on the findings, single-stage laparoscopic surgery is confirmed to aid in the diagnosis and treatment of gallbladder injury in the presence of a common bile duct cyst.
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Affiliation(s)
- Tran Thanh Tri
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Ho Phi Duy
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Luu-Nguyen An Thuan
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Phan Tuan Kiet
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Truong-Thi Yen Nhi
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Nguyen-Thi Tuyen Tran
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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2
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Jafari A, Reihani H, Karbasian F, Darban B, Dehghani SM. Chylous ascites as a rare complication of abdominal trauma in a 7-year-old girl: A case report. Clin Case Rep 2023; 11:e7408. [PMID: 37405045 PMCID: PMC10315450 DOI: 10.1002/ccr3.7408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/06/2022] [Accepted: 05/02/2023] [Indexed: 07/06/2023] Open
Abstract
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.
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Affiliation(s)
- Anahita Jafari
- Gastroenterology and Hepatology Research CenterShiraz University of Medical SciencesShirazIran
| | - Hamid Reihani
- School of MedicineShiraz University of Medical SciencesShirazIran
| | - Fereshteh Karbasian
- Department of Pediatric Gastroenterology and HepatologyIran University of Medical SciencesTehranIran
| | - Behnaz Darban
- Department of Pediatric Gastroenterology and HepatologyIran University of Medical SciencesTehranIran
- Department of Pediatric GastroenterologyHormozgan University of Medical SciencesBandar AbbasIran
| | - Seyed Mohsen Dehghani
- Gastroenterology and Hepatology Research CenterShiraz University of Medical SciencesShirazIran
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3
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Abstract
Isolated thoracic duct injury is an uncommon clinical event and is rare in the setting of trauma. We describe a case of an isolated thoracic duct injury resulting in the development of bilateral chylothorax following a motor vehicle collision in the absence of any other definable injury. We outline the initial patient presentation and diagnosis. After failing a trial of conservative management the patient underwent lymphangiography followed by thoracic duct ligation with pleurodesis. This case highlights the importance of recognizing thoracic duct injury following trauma.
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Affiliation(s)
- Shelby Champion
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Daniele Wiseman
- Department of Medical Imaging, London Health Science Centre, London, Ontario, Canada
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4
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Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther 2017; 46:816-824. [PMID: 28892178 DOI: 10.1111/apt.14284] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/15/2017] [Accepted: 08/11/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance. AIM To review the current diagnostic approach and management of chylous ascites. METHODS A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included. RESULTS Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support. CONCLUSIONS Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.
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Affiliation(s)
- B Lizaola
- Department of Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
| | - A Bonder
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - H D Trivedi
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E B Tapper
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - A Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, University of Barcelona, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona, Spain
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5
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Chylous Ascites: Evaluation and Management. ISRN HEPATOLOGY 2014; 2014:240473. [PMID: 27335837 PMCID: PMC4890871 DOI: 10.1155/2014/240473] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 12/19/2013] [Indexed: 02/07/2023]
Abstract
Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.
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Gomes CS, Handa GI, Silveira FP, Buzingnani VZ, Binati FM, Rasera ESL. Tratamento cirúrgico da ascite quilosa. J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000200017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A ascite quilosa é uma complicação rara após procedimentos cirúrgicos e trauma abdominal, apresentando elevada morbidade e difícil manejo. Nos casos refratários ao tratamento clínico habitual, o tratamento cirúrgico se impõe, apesar da baixa taxa de sucesso. Dois casos são apresentados: o primeiro paciente foi vítima de trauma abdominal contuso e o segundo foi submetido a hernioplastia hiatal a Nissen videolaparoscópica, ambos evoluindo com ascite quilosa que necessitou de tratamento cirúrgico através da ligadura do ducto torácico, junto aos pilares diafragmáticos. Os pacientes evoluíram com melhora clínica e ausência de ascite após 24 meses de seguimento.
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Plummer JM, McFarlane ME, McDonald AH. Chylous ascites associated with chylothorax; a rare sequela of penetrating abdominal trauma: a case report. J Med Case Rep 2007; 1:149. [PMID: 18036251 PMCID: PMC2170448 DOI: 10.1186/1752-1947-1-149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 11/25/2007] [Indexed: 11/10/2022] Open
Abstract
We present the case of a patient with the rare combination of chylous ascites and chylothorax resulting from penetrating abdominal injury. This patient was successfully managed with total parenteral nutrition. This case report is used to highlight the clinical features and management options of this uncommon but challenging clinical problem.
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Affiliation(s)
- Joseph M Plummer
- Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Kingston 7, Jamaica.
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Abstract
The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.
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Affiliation(s)
- James M. Haan
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | | | - Timothy J. Novosel
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M. Stein
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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Abstract
Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.
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Affiliation(s)
- Tony Almakdisi
- Temple University/Conemaugh Memorial Hospital, Department of Medicine, Johnstown, Pennsylvania 15905, USA.
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10
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Abstract
We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.
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Affiliation(s)
- Sharmila Dissanaike
- From the Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - John A. Griswold
- From the Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ari Halldorsson
- From the Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Eldo E. Frezza
- From the Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
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11
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Affiliation(s)
- Andrés Cárdenas
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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12
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Resende Neto JBD, Pinto DM, Abrantes WL. Ascite quilosa traumática. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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13
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Abstract
PURPOSE Postoperative chylous ascites is a rare complication of retroperitoneal and mediastinal surgery that represents a difficult management problem due to the serious mechanical, nutritional and immunological consequences of the constant loss of protein and lymphocytes. We reviewed the topic of postoperative chylous ascites with special emphasis on the relevant diagnostic and imaging modalities. We propose a novel management algorithm. MATERIALS AND METHODS We performed a MEDLINE search of the literature on chylous ascites using chyloperitoneum as the subject heading and chylous ascites as an additional key word. The search yielded 651 articles. We focused on 102 series, collective reviews and mainly case reports related to the issue of postoperative chylous ascites. RESULTS We propose a novel algorithm based on a step-up approach aimed at promoting decreased lymph production and flow as well as maintaining nutritional balance. The management algorithm integrates repeat palliative paracentesis, dietary measures, total parenteral nutrition therapy, peritoneovenous shunting and surgical closure of the lymphoperitoneal fistula. Due to the remarkable effectiveness of somatostatin therapy for the closure of lymphatic fistula somatostatin therapy should be attempted with or without total parenteral nutrition early in the course of treatment of chylous ascites before any invasive steps are taken. CONCLUSIONS Various management modalities may be used successfully to treat chylous ascites. Therefore, treatment should be individualized and adjusted to the severity of lymphatic leakage and its consequences. The outcome mostly depends on the underlying pathological condition. Thus, in the absence of malignant or congenital underlying pathology the prognosis in cases of postoperative chylous ascites is good with the majority responding to conservative measures.
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Affiliation(s)
- Ilan Leibovitch
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Beshay VE, Beshay JE, Rosenberg AJ. Chylous ascites: a case of child abuse and an overview of a rare condition. J Pediatr Gastroenterol Nutr 2001; 32:487-9. [PMID: 11396820 DOI: 10.1097/00005176-200104000-00019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- V E Beshay
- Department of Pediatric Gastroenterology, Brody School of Medicine at East Carolina University, Greenville, North Carolina 27858, USA
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Affiliation(s)
- O O Aalami
- Department of Surgery, University of California, Davis-East Bay, Oakland, Calif, 94602, USA
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Abstract
An 8-year-old boy was evaluated for blunt abdominal trauma after a motor vehicle crash. In the course of his workup, a computed tomography (CT) scan of the abdomen was suspicious for a duodenal injury. At surgery, the duodenum was found to be normal; however, a rupture of the cisterna chyli was identified. This injury was repaired, and the boy made an uneventful recovery. This report is one of few in the literature describing isolated injury to the cisterna chyli after blunt abdominal trauma.
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Affiliation(s)
- C M Calkins
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 80204, USA
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