Lymphomas and chylous ascites: review of the literature

Laboratory investigation of peritoneal fluids: an updated practical approach based on the available evidence

Even though analysis of peritoneal fluids (PF) is often requested to medical laboratories for biochemical and morphological tests, there is still no mutual agreement on what the most appropriate way is to manage PF samples and which tests should be appropriately executed. In this update, we tried to identify the most useful tests for PF analysis to establish best practice indications. We performed a literature review and examined available guidelines to select the most appropriate tests by an evidence-based approach. Accordingly, the basic PF profile should include (1) serum to effusion albumin gradient and (2) automated cell counts with differential analysis. This profile allows to determine the PF nature, differentiating between 'high-albumin gradient' and 'low-albumin gradient' effusions, which helps to identify the pathophysiological process causing the ascites formation. Restricted to specific clinical situations, additional tests can be requested as follows: PF lactate dehydrogenase (LDH) and glucose, to exclude (LDH) or confirm (glucose) secondary bacterial peritonitis; PF total protein, to differentiate ascites of cardiac origin from other causes; PF (pancreatic) amylase, for the identification of pancreatic ascites; PF bilirubin, when a choleperitoneum is suspected; PF triglycerides, in differentiating chylous from pseudochylous ascites and PF creatinine, to detect intraperitoneal urinary leakage.

Aetiology and diagnostic utility of serum ascites albumin gradient in children with ascites

BACKGROUND

Ascites in children is multifactorial and serum ascites albumin gradient (SAAG) ≥1.1 helps differentiate portal hypertension (PHTN) related from non-PHTN ascites.

AIMS

We evaluated the aetiology and diagnostic accuracy of SAAG in children with ascites.

METHODS

Children with ascites were retrospectively evaluated. Etiological diagnosis was based on clinical presentation and investigations. All cases with ascitic fluid analysis and a definite diagnosis were included for calculating the utility of SAAG.

RESULTS

We enrolled 878 children (568[64.7%] boys). Majority were PHTN related (638[72.7%]) and secondary to acute viral hepatitis (98,15.4%), acute liver failure (185,29%), chronic liver disease (276,43.3%) and Budd-Chiari syndrome (79,12.4%). Other causes included tubercular (46,5.2%), pancreatic (32,3.6%), chylous (20,2.3%), biliary (12,1.4%), pseudoascites (16,1.8%), infections (46,5.2%), nephrotic (26,2.9%), malignancy (23,2.6%), cardiac (9,1.0%) and others (10,1%). SAAG (n = 305) correctly differentiated PHTN and non-PHTN ascites in 272 (89.2%) cases, with a high sensitivity (97%), specificity (93%) and diagnostic accuracy (95.8%). Reasons for inaccurate SAAG included mixed ascites (n = 9), different day serum and ascitic fluid albumin estimation (n = 5), serum albumin ≤1.1 g/dL (n = 2), chylous ascites (n = 3), hypergammaglobulinemia (n = 1), albumin infusions (n = 1) and unexplained (n = 12).

CONCLUSIONS

Nearly 27% children had non-PHTN related ascites. SAAG differentiates PHTN from non-PHTN ascites with a diagnostic accuracy of 95%.

A case of idiopathic chylous ascites

Chylous ascites is a rare condition found in 1 in 20 000 patients admitted to hospital with abdominal distention. It is caused by a limited number of pathologies but can, in rare situations, be idiopathic. Its management is difficult and usually involves correcting the primary pathology, making idiopathic chylous ascites particularly difficult to manage. We present a case of idiopathic chylous ascites extensively investigated over a period of several years. An incidental finding of B cell lymphoma was initially suspected to have been the primary cause of the ascites; however, after successful treatment of this condition, the patient's ascites did not resolve. Diagnostic difficulties and management are discussed and an overview of the diagnostic process is outlined through this case.

Milky Ascites: A Diagnostic Dilemma

Chylous ascites is a milky-appearing, triglyceride-rich fluid within the abdominal cavity. It is a rare finding that arises from the disruption of the lymphatic system and can be caused by a wide variety of pathologies. Here, we present a diagnostically challenging case of chylous ascites. In this article, we discuss the pathophysiology and various etiologies of chylous ascites, explore the diagnostic tools available, and highlight the management strategies implemented in this rare finding.

Recurrent chylous ascites in patient with previous retroperitoneal radiation treatment

Chylous ascites is the accumulation of lymphatic fluid in the peritoneal cavity due to disruption of lymphatic drainage caused due to obstruction or trauma. We report a man in his 60s who was previously treated for diffuse large B cell lymphoma with radiation to bulky abdominal/mesenteric lymphadenopathy. He was later found to have recurrent chylous ascites several years later, requiring multiple paracentesis. Recurrent lymphoma was ruled out with negative cytology of peritoneal fluid as well as lymph node biopsy with no evidence of malignancy. We believe that the patient had obstruction of lymphatic drainage due to previous radiation therapy causing fibrosis. The patient underwent lymphangiography which did not visualise the central lymphatic duct within the abdomen raising suspicion for obstruction of the ducts secondary to previous radiation.

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.

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.

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.

Application of ultrasound-guided intranodal lymphangiography and embolisation in cancer patients with postoperative lymphatic leakage

BACKGROUND

Traumatic lymphatic leakage is a rare but potentially life-threatening complication. The purpose of this study was to introduce ultrasound-guided intranodal lymphangiography and embolisation techniques for postoperative lymphatic leakage in patients with cancer.

METHODS

From January 2018 through June 2020, seven cancer patients (three males, four females, aged 59-75 years [mean 67.57 ± 6.11 years]) developed lymphatic leakage after abdominal or pelvic surgery, with drainage volumes ranging from 550 to 1200 mL per day. The procedure and follow-up of ultrasound-guided intranodal lymphangiography and embolisation were recorded. This study retrospectively analysed the technical success rate, operative time, length of hospital stay, clinical efficacy, and complications.

RESULTS

The operation was technically successful in all patients. Angiography revealed leakage, and embolisation was performed in all seven patients (7/7, 100%). The operative time of angiography and embolisation was 41 to 68 min, with an average time of 53.29 ± 10.27 min. The mean length of stay was 3.51 ± 1.13 days. Lymph node embolisation was clinically successful in five patients (5/7, 71.43%), who had a significant reduction in or disappearance of chylous ascites. The other two patients received surgical treatment 2 weeks later due to poor results after embolisation. All patients were followed for 2 weeks. No serious complications or only minor complications were found in all the patients.

CONCLUSIONS

Ultrasound-guided intranodal lymphangiography and embolisation were well tolerated by the patients, who experienced a low incidence of complications. Early intervention is recommended for cancer patients with postoperative lymphatic leakage.

Chylous ascites following repair of total anomalous pulmonary venous connection coexisting with a persistent left superior vena cava in a neonate: a case report

Chylous ascites refers to the accumulation of lymphatic fluid in the peritoneal cavity. The causes of chylous ascites are various, and commonly include traumatic injury and obstruction, which disrupt the lymphatic system. In addition, cardiothoracic surgery may injure the thoracic duct and lead to chylothorax. However, there are very few reported cases of isolated chylous ascites developing following cardiothoracic surgery. In this paper, we report a case of postoperative chylous ascites in a full-term neonate. The infant underwent cardiothoracic surgery via thoracotomy to repair total anomalous pulmonary venous connection coexisting with a persistent left superior vena cava on day of life 17, and there was a significant increase in abdominal girth on postoperative day 12 (day of life 29). Abdominal ultrasound revealed an 8 mm thick ascites without pleural effusion. Abdominal paracentesis was performed and the milky-white peritoneal fluid was positive for Sudan III staining and the chylous test. The triglyceride concentration of the ascitic fluid was 691 mg/dL and the concentration of protein was 39.4 g/L. Additionally, the ascitic fluid also contained 6 360×10⁶/L of white blood cells, predominantly lymphocytes. These results suggested the infant developed chylous ascites. Conservative management with fasting and medium-chain triglycerides-based formula successfully resolved the chylous ascites without reoccurrence. We present our experience of this rare condition and discuss the possible causes of chylous ascites in this case.

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.

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.

Quiloperitoneo espontáneo en el embarazo

Introducción. El quiloperitoneo consiste en la presencia de fluido linfático en la cavidad intraabdominal, complicación poco descrita en el embarazo y cuyas repercusiones no están bien establecidas. Reporte de caso. Se presenta el caso de una mujer gestante con embarazo de 36,5 semanas, sin comorbilidades, hospitalizada por presentar cifras tensionales elevadas asociadas a síntomas de encefalopatía hipertensiva y bradicardia fetal sostenida; se le practicó una cesárea urgente en la cual se evidenció corioperitoneo incidental. La tomografía computarizada abdominal de control no demostró alteraciones. Discusión. Se descartaron las principales causas del quiloperitoneo, las cuales son neoplasia maligna y trauma. Se consideró que se trataba de un quiloperitoneo espontáneo posiblemente relacionado con la congestión pélvica propia del embarazo, por vasodilatación secundaria al influjo hormonal, aumento de la presión intraabdominal y contribución del volumen ascítico por la preeclampsia, que genera ruptura traumática de los vasos linfáticos. Conclusión. La ascitis quilosa es una entidad poco frecuente que puede verse asociada con el embarazo. Es fundamental el criterio acertado del ginecoobstetra para determinar tempranamente la etiología.

Chylous Ascites: An Unusual Complication of Peritoneal Dialysis. A Case Report and Literature Review

Chylous ascites is a rare complication in patients undergoing peritoneal dialysis. It may occur due to traumatic peritoneal dialysis catheter insertion or other causes. It is important to be aware of this condition as it may be confused with peritonitis, and antibiotics may be inappropriately administered. We report a case of chylous ascites occurring after catheter insertion and discuss management of this condition.

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.

A 28-Year-Old Woman with Ascites and Multiple Focal Spleen Lesions

Serous effusions complicating the course of lymphomas occur commonly in the pleural space but seldom in the peritoneum, where they most often present as chylous ascites with diagnostic cytology. Almost invariably, in these rare cases, the serum to ascites albumin gradient is low. We describe a 28-year-old woman with anasarca, ascites and a serum to ascites albumin gradient of 1.1 g/dl, consistent with portal hypertension. No tumour cells were detected in the ascitic fluid. However, a CT scan of the chest and abdomen disclosed liver and spleen enlargement and multiple enlarged retroperitoneal lymph nodes, suspicious for a lymphoproliferative disorder. Bone marrow aspiration and biopsy were not diagnostic, so a decision was made to proceed with a splenectomy despite the onset of low-grade disseminated intravascular coagulation.

Surgery was uneventful. Diffuse large B cell lymphoma was diagnosed. A liver biopsy taken at the time of surgery demonstrated that the liver parenchyma was massively infiltrated by reactive T lymphocytes surrounding rare large CD20+ tumour cells. This infiltrate had likely led to increased portal pressure attended by ascites formation, which resolved completely after chemotherapy. The case emphasizes the rewards of pursuing a diagnosis supported by a high prior probability even in the presence of apparently discordant laboratory findings, as well as the importance of performing a diagnostic splenectomy in case of splenomegaly with unexplained focal lesions.

Chylous Ascites due to Mantle Cell Lymphoma

Chylous ascites is rare and results in accumulation of lymph in the abdominal cavity, due to several mechanisms. The ascitic liquid is milky because of the high concentration of triglycerides (>200 mg/dl). The higher incidence compared to the past is explained by increased survival of patients with cancer and more aggressive surgery. We describe the case of an 87-year-old man admitted to the geriatric ward due to general oedema, chylous ascites and loss of weight, explained by mantle cell lymphoma.

A primary retroperitoneal anaplastic lymphoma kinase-positive anaplastic large cell lymphoma with tumor thrombosis

Anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) is a T cell subtype of non-Hodgkin’s lymphoma (NHL). Typically, lymphoma rarely infiltrates vascular structure. In this article, we present a case of retroperitoneal ALK-positive ALCL with splenic venous tumor thrombosis. A 62-year-old patient presented to our institute with the symptoms of epigastric pain, abdominal distension, and reduced bowel movement. Physical examination indicated no enlarged peripheral lymph nodes or abdominal mass. Laboratory workup revealed granulocytosis, abnormal coagulation function, and normal level of lactic dehydrogenase (LDH). Contrast-enhanced computed tomography (CT) showed a retroperitoneal mass with involvement of pancreas and duodenum and formation of splenic venous tumor thrombus. Ultrasonography-guided retroperitoneal lesion biopsy confirmed the diagnosis of ALK-positive ALCL. The patient was able to tolerate oral intake after two cycles of chemotherapy and showed no sign of lymphoma by positron emission tomography (PET)-CT after the fourth cycle of chemotherapy. In spite of its rarity, lymphoma should be taken into account as a differential diagnosis of other malignancies with tumor thrombosis.

Feline low-grade alimentary lymphoma: an emerging entity and a potential animal model for human disease

BACKGROUND

Low-grade alimentary lymphoma (LGAL) is characterised by the infiltration of neoplastic T-lymphocytes, typically in the small intestine. The incidence of LGAL has increased over the last ten years and it is now the most frequent digestive neoplasia in cats and comprises 60 to 75% of gastrointestinal lymphoma cases. Given that LGAL shares common clinical, paraclinical and ultrasonographic features with inflammatory bowel diseases, establishing a diagnosis is challenging. A review was designed to summarise current knowledge of the pathogenesis, diagnosis, prognosis and treatment of feline LGAL. Electronic searches of PubMed and Science Direct were carried out without date or language restrictions.

RESULTS

A total of 176 peer-reviewed documents were identified and most of which were published in the last twenty years. 130 studies were found from the veterinary literature and 46 from the human medicine literature. Heterogeneity of study designs and outcome measures made meta-analysis inappropriate. The pathophysiology of feline LGAL still needs to be elucidated, not least the putative roles of infectious agents, environmental factors as well as genetic events. The most common therapeutic strategy is combination treatment with prednisolone and chlorambucil, and prolonged remission can often be achieved. Developments in immunohistochemical analysis and clonality testing have improved the confidence of clinicians in obtaining a correct diagnosis between LGAL and IBD. The condition shares similarities with some diseases in humans, especially human indolent T-cell lymphoproliferative disorder of the gastrointestinal tract.

CONCLUSIONS

The pathophysiology of feline LGAL still needs to be elucidated and prospective studies as well as standardisation of therapeutic strategies are needed. A combination of conventional histopathology and immunohistochemistry remains the current gold-standard test, but clinicians should be cautious about reclassifying cats previously diagnosed with IBD to lymphoma on the basis of clonality testing. Importantly, feline LGAL could be considered to be a potential animal model for indolent digestive T-cell lymphoproliferative disorder, a rare condition in human medicine.

Cloudy Dialysate as the Initial Presentation for Lymphoma

Turbid dialysate in a patient on peritoneal dialysis is usually due to peritonitis and almost all these patients are started on empirical antibiotics pending cultures. However, in few of them with culture negative fluid, this could represent other etiologies like chyle, which requires more intensive investigations, and analysis of fluid itself reveals some rare diagnosis. We present one such report of chylous ascites with prompt investigation leading to a diagnosis of malignancy in a peritoneal dialysis patient.

Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction. The underlying etiologies for CA have been classified as traumatic, congenital, infectious, neoplastic, postoperative, cirrhotic or cardiogenic. Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries, in this article we have attempted to reclassify CA based on portal and non-portal etiologies. The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of >200 mg/dL. The management consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Some studies have also supported the use of agents such as orlistat, somatostatin, octreotide and etilefrine. Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt (commonly known as TIPS), peritoneal shunt, angiography with embolization of a leaking vessel, and laparotomy remain as treatment options for cases refractory to medical management.

Retroperitoneal Fibrosis as a Cause of Chylous Ascites

Retroperitoneal fibrosis is a rare condition characterized by chronic inflammation and marked fibrosis of the retroperitoneal tissue, often leading to entrapment of abdominal organs. We report a 69-year-old white man who presented with a 5-week history of gradual onset of progressive abdominal distension. He had no history or risk factors for an underlying liver condition. Ascites and a retroperitoneal mass encasing the major abdominal vessels were revealed on imaging. Biopsies of the mass confirmed the presence of retroperitoneal fibrosis, and the ascitic fluid was milky, consistent with chylous ascites. We discuss this rare presentation and the challenges of treatment for chylous ascites caused by RPF, including the role for supportive treatment.

Atraumatic chylous ascites: an unusual presentation of bladder cancer

We describe a case of bladder cancer presenting with atraumatic chylous ascites, which remains an extremely rare presentation of this condition. A previously well, elderly ex-smoker with no prior history of abdominal surgery was referred for investigation of progressive dyspnoea, increasing peripheral oedema and new-onset ascites, on a background of long-standing alcohol consumption (four standard drinks daily). Liver biochemistry and coagulation profile were normal apart from marked hypoalbuminaemia. Doppler ultrasound of the liver demonstrated normal echotexture and patent vasculature. Abdominal paracentesis yielded 8 L of milk-coloured, triglyceride-rich fluid with abundant malignant cells. Urine cytology demonstrated malignant transitional cells, with radiological evidence of a large enhancing bladder mass, with evidence of adjacent lymphadenopathy and omental involvement. A diagnosis of metastatic stage IV transitional cell bladder cancer was made. The patient declined palliative chemotherapy and passed away 2 months after their initial presentation.

Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions

OBJECTIVES

Lipoprotein electrophoresis is the gold standard for the detection of chylous ascites and pleural effusions. It is, however, not suitable as a front-line test and not widely available. Most clinicians must rely solely on the quantitative determination of lipids. The aim of this work was to establish lipid cut-off values for the presence of chylomicrons in pleural and peritoneal fluid.

DESIGN AND METHODS

Triglyceride and cholesterol levels from 113 peritoneal and 154 pleural fluid samples investigated for chylomicrons via lipoprotein electrophoresis were considered. Receiver operating characteristic analyses were performed and cut-off levels determined.

RESULTS

54 peritoneal and 59 pleural fluid samples were positive for chylomicrons. In peritoneal fluid, triglycerides and triglycerides/cholesterol ratio exhibited areas under the curve (AUC) not significantly different from each other, but significantly larger than cholesterol alone. The AUC for triglycerides in pleural fluid was significantly larger than the AUCs for cholesterol and the triglycerides/cholesterol ratio. Triglyceride cut-offs with maximum Youden-Index, sensitivity >95%, and specificity >95% were calculated to be 187, 148, and 246mg/dl (2.13, 1.69, and 2.80mmol/l) for peritoneal fluid, and 240, 94, and 240mg/dl (2.74, 1.07, and 2.74mmol/l) for pleural fluid.

CONCLUSIONS

Triglyceride levels are the best parameter to detect chylous body fluids when lipoprotein electrophoresis is not available. Single-point triglyceride cut-offs of 187 and 240mg/dl (2.13 and 2.74mmol/l) or alternatively equivocal ranges of 148-246 and 94-240mg/dl (1.69-2.80 and 1.07-2.74mmol/l) were established for peritoneal and pleural fluid, respectively.

Percutaneous Treatment of Chylous Ascites

Chylous ascites occurs as a result of lymphatic leakage, which contains high concentration of triglycerides. The leakage is caused by various benign or malignant etiologies ranging from congenital lymphatic abnormality to trauma. Lymphangiography has been shown to be effective in the diagnosis of lymphatic leakage and has also been reported to have therapeutic outcome. The development of intranodal technique for lymphangiography has recently made the procedure more widespread. As an adjunctive procedure, percutaneous embolization may be performed which involves use of embolic agents such as N-butyl cyanoacrylate and coil to occlude the leak. Embolization in the lymphatic system was first made popular by the introduction of thoracic duct embolization by Cope et al and has recently led to the development of various techniques for percutaneous embolization. This article reviews the options and techniques for percutaneous treatment of lymphatic leaks in patients presenting with chylous ascites.

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.

A Case of Chyloperitoneum Secondary to Follicular Lymphoma and a Review of Prognostic Implications

Chyloperitoneum, or chylous ascites, is a rare condition characterized by milky-appearing fluid with elevated triglyceride content and the presence of chylomicrons. Malignancy, specifically lymphoma, is reported to be the predominant cause in Western countries. Previously, the prognosis for patients with chyloperitoneum due to lymphoma has been reported as poor. We present a case of chyloperitoneum and chylothorax due to follicular lymphoma with excellent response to bendamustine and Rituxan. A review of the literature indicates that patients with chyloperitoneum associated with lymphoma generally have a favorable response to contemporary treatment regimens.

Nutritional support in adults with chyle leaks

We provide a practical approach to the complex management problem of chyle leaks that occur after surgical procedures or trauma, or when they occur spontaneously in association with malignancies. The volume of chyle loss causes significant problems due to loss of fluid, electrolytes, proteins, and lymphocytes, causing deleterious effects on wound healing and immunity. Enteral feeding is not always possible as long chain fatty acids are absorbed through the intestinal lacteals, the original source of chyle. Regular diets increase the leak and delay healing. Nutritional support involves coordinated care between healthcare providers to provide a combination of various modalities, including nil by mouth, parenteral nutrition, enteral feeding with formula modifications, and oral diet.

Incidental Chylous Ascites at the Time of Cesarean Section

Chylous ascites has multiple etiologies including malignancies, liver cirrhosis, intraperitoneal infections, and trauma. It is rarely reported in pregnancy. We report a case of chylous ascites noted at the time of cesarean section performed at 35 weeks of gestation on a patient with preeclampsia and suspected placental abruption. The diagnosis and treatment of chylous ascites as well as the pregnancy outcome are presented. A literature review of chylous ascites in pregnancy is discussed as well.

Chylous Ascites: Evaluation and Management

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.

The lymphatic vascular system in liver diseases: its role in ascites formation

The lymphatic system is part of the circulatory system and plays a key role in normal vascular function. Its failure plays a crucial role in the development and maintenance of various diseases including liver diseases. Lymphangiogenesis (the growth of lymphatic vessels) and changes in the properties of lymphatic vessels are associated with pathogenesis of tumor metastases, ascites formation, liver fibrosis/cirrhosis and portal hypertension. Despite its significant role in liver diseases and its importance as a potential therapeutic target for those diseases, the lymphatic vascular system of the liver is poorly understood. Therefore, how the lymphatic vascular system in general and lymphangiogenesis in particular are mechanistically related to the pathogenesis and maintenance of liver diseases are largely unknown. This article summarizes: 1) the lymphatic vascular system; 2) its role in liver tumors, liver fibrosis/cirrhosis and portal hypertension; and 3) its role in ascites formation.

Chylous ascites: Why exercise is bad for you

INTRODUCTION

The development of chylous ascites is usually associated with trauma, iatrogenic or otherwise. Blunt abdominal trauma producing hyperextension or hyperflexion may cause disruption to lymphatic vessels causing chylous ascites.

PRESENTATION OF CASE

This report describes the case of a 38-year-old gentleman who presented to the emergency department with severe abdominal pain after completing a triathlon. As the patient was in severe pain, an abdominal CT was performed which demonstrated a possible mid gut volvulus. Subsequent laparotomy noted a significant volume of intra-abdominal chyle with no other abnormalities.

DISCUSSION

This is the first report of chylous ascites occurring without associated abdominal pathology after a period of strenuous exercise.

CONCLUSION

Chylous ascites can occur as a result of hyperreflexion and hyperextension injuries sustained during strenuous exercise.

Chylous ascites secondary to giant liver hemangioma

Chylous ascites is rare in clinical practice. It is characterized by milky-appearing peritoneal fluid with a triglycerides concentration of >1.25 mmol/l (110 mg/dl). Its pathophysiology is related to a disruption in the normal lymphatic flow. It is more common after trauma (including post surgery), neoplasia or atypical infections such as tuberculosis or filariasis. Other rare medical causes have been reported. The treatment is supportive and focused on correction of the underlying pathology. We report here the first case of chylous ascites caused by giant liver hemangioma and discuss the management of this condition.

Spontaneous resolution of chylous ascites following delivery: a case report

Introduction

Chyloascites or chyloperitoneum, which can be caused by different factors, is a process of eruption of one or many lymphatic vessels spontaneously. Malignant processes, inflammation or trauma can cause a sudden burst in a lymphatic vessel which will lead to a collection of milky fluid in any space of the human body with the abdominal cavity being the most common location. Chyloperitoneum is rare during pregnancy and this case is the fifth described worldwide.

Case presentation

We describe a case of chyloascitis in a 27-year-old primigravida Middle Eastern woman, found coincidentally during cesarean section. Free fluid was found in the abdominal cavity with no source of trauma or masses. An abdominal drain remained in situ for six days. The milky fluid was sent for biochemical analysis and found to be positive for triglycerides. Her postoperative course was uneventful. A computed tomography scan of the abdomen and pelvis was negative for fluid collection, tumors or other lesions. While this is the fifth case of chylous ascitis associated with pregnancy, it is the second found to be spontaneous with no obvious cause described to date.

Conclusion

Chylous ascitis is not always associated with tumors, inflammation or trauma. It can, although rarely, be associated with pregnancy. The course of pregnancy is usually uncomplicated in the cases published to date. This fifth case serves as a reminder for obstetricians, when presented with similar findings, to consider chylous ascitis as one of the differential diagnoses. Early diagnosis and appropriate treatment is vital for improved outcomes for the mother and the fetus.

Chylous ascites caused by acute pancreatitis with portal vein thrombosis

Chylous ascites is defined as the accumulation of chyle in the peritoneum due to obstruction or rupture of the peritoneal or retroperitoneal lymphatic glands. Chylous ascites that arises from acute pancreatitis with portal vein thrombosis is very rare. We report here on a case of chylous ascite that was caused by acute pancreatitis with portal vein thrombosis, in which the patient showed an impressive response to conservative therapy with total parenteral nutrition and octerotide. We also review the relevant literature about chylous ascites with particular reference to the management of this rare disease.

Acute appendicitis together with chylous ascites: is it a coincidence?

Acute chylous ascites is a rarely seen clinical picture, therefore, examination findings are often confused with acute appendicitis. To the best of our knowledge, there is no publication to date showing the occurrence of them together. This study presents the treatment plan for a 25-year-old male patient with both acute chylous ascites and appendicitis. Surgical findings were retrocaecal appendicitis, evident lymphangiectasia in the proximal segment of jejunum, and approximately 3 lt of chylous fluid. An appendectomy was performed and drainage was applied. Low-fat total parenteral nutrition (TPN) and octreotide treatment were administered for 7 days postoperatively. We also present a general review of some studies on chylous ascites, which have been published in the English language medical literature since 1910.