Chylous ascites: an unusual case

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A 70-year-old man presented with 6 weeks' history of increasing abdominal distension and shortness of breath. He was completely independent before this admission. Relevant past medical history included a recent normal colonoscopy for altered bowel habit. Although abstinent for 1 year, his alcohol consumption had been up to 100 units/week for over 50 years. He was on no medications and had never smoked. Clinical examination revealed massive ascites. Bloods on admission showed a normal platelet count, mild anaemia, haemoglobin 11.4 g/dl and mild renal impairment, urea 10.4 mmol/litre and creatinine 140 umol/litre. Liver function tests and a full liver screen including hepatitis virus B and C, autoantibodies, alfa-fetoprotein and ferritin were normal. Ultrasound of the abdomen showed a nodular liver suggesting cirrhosis with widespread ascites. Chest X-ray was normal. Ascitic fluid aspiration revealed milky white ascitic fluid with a very high triglyceride content of 17.4 mmol/litre (normal <2.2 mmol/litre) in keeping with chylous ascites and negative for microbiology including acid-fast bacilli. The ascites did not respond to diuretic therapy. He suffered a sudden respiratory arrest and was resuscitated and transferred to the high dependency unit. Therapeutic abdominal paracentesis was performed, draining 5 litres of chylous fluid. Urgent computed tomography of the chest, abdomen and pelvis showed a right pulmonary artery embolus and bilateral femoral vein thrombosis. Bony metastases were also identified throughout the axial skeleton, with para-aortic lymphadenopathy and a large nodal mass in the small bowel mesentery (Figure 1). The radiological differential included prostate cancer and lymphoma. Prostate-specific antigen was elevated at 1611 ug/litre (normal < 5 ug/litre) and subsequent computed tomography-guided biopsy of the mesenteric mass revealed fibro-fatty connective tissue infiltrated by tumour cells with immunohistochemistry positive for prostate-specific antigen, consistent with extensive metastatic prostate cancer with nodal and bony metastases (Figure 2). Hormonal treatment with leuprorelin acetate and bicalutamide was started on transfer to urology but unfortunately his clinical condition deteriorated, and he died 2 months later.