Sirmad Chaudhary, MD, Wenjing Cai, MD, Charles F. Closson, MD, Nancy T. Kubiak, MD; University of Louisville, Louisville, KY
Introduction: Chylous ascites refers to the accumulation of milky-appearing fluid in the peritoneal cavity. A triglyceride count >200 mg/dL in the ascites fluid is considered diagnostic. Recognition of this clinical entity is important, as first line management focuses on dietary changes as opposed to the use of diuretics.
Methods: A 38-year-old female with Von Hippel-Lindau syndrome presented to the emergency department complaining of progressively worsening abdominal distention and pain. Two months prior to presentation, she underwent left radical nephrectomy for renal cell carcinoma. Post-operatively, she developed a right-sided chylothorax requiring two thoracenteses. On exam, she was afebrile, hemodynamically stable, and had a distended abdomen with tenderness to palpation in the bilateral lumbar regions. Imaging of the abdomen revealed moderate to large volume ascites. A diagnostic paracentesis was performed to rule-out spontaneous bacterial peritonitis, and milk-like fluid was aspirated. Cytology was negative for malignant cells, and fluid studies were consistent with chylous ascites; the triglyceride level was 1779 mg/dL. The patient received education on a fat-free diet and was discharged home. She developed pain and re-accumulation of ascites fluid a month later and underwent a repeat paracentesis. After consultation with a dietician and her outpatient gastroenterologist, she was placed on a peptide-based semi-elemental formula twice a day and an additional no-fat meal. She had no signs of fluid re-accumulation at follow-up visits. Discussion: Chylous ascites is rare, with an estimated incidence of 1 in 20,000 admissions. It can be due to trauma, including surgery, or non-traumatic causes such as malignancy or cirrhosis. In the setting of nephrectomy, the incidence is between 3.8-5.1%, and the cause is likely due to either adhesions or extrinsic compression of lymphatic vessels. Diagnosis is made via paracentesis. Treatment aims to avoid loss of fluids and electrolytes, malnutrition, and immunoglobulins. First-line therapy involves dietary modifications, e.g. a high-protein, low-fat diet with medium-chain triglycerides which can directly be absorbed by enterocytes and bypass lymphatic vessels. Lack of improvement may necessitate pharmacotherapy with medications such as orlistat, octreotide, or etilefrine. Bowel rest and total parenteral nutrition may be considered as well. Percutaneous embolization, TIPS, peritovenous shunts, or surgery are reserved for refractory ascites.
Disclosures: Sirmad Chaudhary indicated no relevant financial relationships. Wenjing Cai indicated no relevant financial relationships. Charles Closson indicated no relevant financial relationships. Nancy Kubiak indicated no relevant financial relationships.