A Rare Case of Ascites

Abstract

Chylous ascites (CA) is a rare form of ascites most frequently caused by lymphatic abnormalities. Diagnosis is established based on clinical presentation, ascitic fluid analysis, and imaging. Here we present a case of CA that occurred as a complication of intra-abdominal aortic surgery. A 56 year-old female with peripheral arterial disease, COPD, anxiety, and peptic ulcer disease presented with abdominal pain/swelling worsening over 1 week. She had been admitted 1 month prior with abdominal pain and was found to have a right renal artery occlusion, SMA occlusion and celiac stenosis. She underwent a supraceliac aorta to celiac and inferior mesenteric artery bypass and had been discharged home 1 week prior to this presentation. Review of systems was notable for only loss of appetite and 30 lbs unintentional weight loss over 3 years. She had no prior liver disease, denied EtOH or illicit drug use, no incarcerations. Her vitals were normal and on exam she was found to have a tense, tender abdomen, with positive fluid wave. Her midline incision was clean, dry, and intact. She had no stigmata of chronic liver disease. Labs were notable for a WBC 15.6, Plt 387, Cr 0.5, Albumin 2.8, T. Bili. 0.5, AST 24, ALT 17, Alk. Phos. 84, and INR 1.0. Ascitic fluid analysis showed cloudy yellow fluid with 5354 RBCs, 1009 WBCs, 90% lymphs, 2% segs, LDH 101, glucose 89, triglycerides (TG) 131 mg/dL, Albumin 1.8 g/dL, protein 3.0 g/dL, and a SAAG of 1.0. Gram stain, culture, and AFB were negative. CT abdomen and pelvis with IV contrast was notable for large volume ascites, normal liver and spleen, and no masses. Lymphangiography (LAG) did not reveal chyle leak. The onset of ascites after aortic surgery raised our suspicion for CA from trauma to the lymphatic system. The diagnosis was supported by the ascitic WBC>500 with lymphocyte predominance, glucose <100, total protein of 3, milky appearance, and TG of 131. LAG is an important technique for the detection of lymphatic leaks with reported detection rates of 64-86%. Combining both LAG and CT imaging modalities facilitated identification of a chyle leak. The management of CA consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Our patient was effectively managed with therapeutic paracentesis and initiation of a high-protein, low-fat parenteral diet with medium chain triglyceride supplementation. Upon follow-up 2 months later, her ascites had completely resolved.2331 Figure 1. Typical Characteristics of Chylous Ascites