A Very Rare Case of Chylous Ascites

Abstract

Purpose: Case Report: 62 y/o gentleman with obesity was referred to the hepatology clinic with 3-month history of diarrhea, new onset ascites and 75 lb weight loss. He denied alcohol abuse, chronic liver disease or family history of liver disease. Diarrhea was non-bloody, watery, occurred 20 X per day, awakened him at night and persisted despite fasting. Stool studies were negative. Paracentesis returned chylous ascites. Serum ascites albumin gradient was >1.1 with fluid protein of 3.3 g/dL and cholesterol >1000 g/dL. Labs showed AST 88 U/L, ALT 47 U/L and elevated alkaline phosphatase (AP) level of 155 U/L, INR 1.3. CT scan of abdomen/pelvis revealed hepatomegaly. Colonoscopy with random biopsies were unrevealing. Terminal ileum and appendix were grossly normal. CT scan guided liver biopsy confirmed suspicions of carcinoid. Octreotide scan located a primary small bowel neoplasm in the mid-abdomen with two liver metastatic lesions. Upon further review of the initial CT scan, jejunal non-specific narrowing was found with subtle small bowel dilation. Discussion: Carcinoids are rare neuroendocrine tumors arising from amine precursor uptake and decarboxylation (APUD) cells. Chylous ascites or leakage of lipid rich lymph is also rare with incidence of approximately 1 in 20,500. Majority of cases are due to inflammatory processes, trauma and congenital causes. The association between carcinoid tumors and chylous ascites is extremely rare and has only been reported in a few case studies. Carcinoid induced chylous ascites is thought to occur either from obstruction of lymph nodes by tumor or the intense mesenteric reaction blocking uptake of peritoneal fluid. Survival studies have demonstrated poor prognosis in patients whose carcinoid induced chylous ascites is a component of their symptoms compared to those patients who had metastatic carcinoid tumor without ascites. Carcinoid should be considered in the differential diagnosis in patients with diarrhea and chylous ascites. Subtle small bowel changes may be missed. Octreotide scan is still an important tool in diagnosing primary carcinoid tumor.Figure: Jejunal non-specific narrowing was found with subtle small bowel dilation.