Chylous Ascites Following Severe Acute Necrotizing Pancreatitis

Abstract

Introduction: The accumulation of milk-like fluid rich in triglycerides within the peritoneal cavity is termed chylous ascites. It results from extravasation of lymph due to disruption of the lymphatic system from trauma or obstruction. Abdominal malignancy and cirrhosis are responsible for the majority of cases in the developed world. Infectious etiologies, such as tuberculosis and filariasis, are most commonly implicated in developing countries. Definitive diagnosis is made by paracentesis, which demonstrates a fluid triglyceride level of greater than 200 mg/dL. Chylous ascites is a rare occurrence and presents a therapeutic dilemma in cases where the underlying disease process is not readily reversible. Very few case reports exist of chylous ascites following severe necrotizing pancreatitis. There is anecdotal evidence in the literature describing improvement with the use of parenteral nutrition and octreotide. Herein, we describe a case of chylous ascites following an episode of severe necrotizing pancreatitis successfully treated with parental nutrition and octreotide. A 70-year-old man with a history of asthma and dyslipidemia suffered a severe episode of acute necrotizing pancreatitis. He presented 3 months after his initial episode of pancreatitis with worsening abdominal distention and early satiety. Imaging revealed ascites in addition to a large pancreatic pseudocyst. A paracentesis was performed, yielding white turbid ascitic fluid with a triglyceride level of 652 mg/dL, consistent with chylous ascites. Furthermore, the amylase level was normal and bacterial culture, fungal culture, AFB, cytology, and flow cytometry were negative. Investigation of underlying etiologies ruled out tuberculosis, malignancy, cirrhosis, and cardiac causes. He was started on parental nutrition and octreotide 150 mcg subcutaneously every 8 hours in an attempt to reduce lymph production. Therapy was continued until a noticeable improvement in ascites was appreciated, a total of 10 days. Repeat paracentesis confirmed resolution of the chylous ascites, with a triglyceride level of 55 mg/dL. It was postulated that chylous ascites ensued after thoracic duct disruption from severe inflammatory changes related to pancreatitis. This hypothesis was further supported by the presence of a coinciding chylothorax at the time of diagnosis. The patient’s hospital course was complicated by infection of the pancreatic necrosis requiring open necrosectomy, which did not reveal any other underlying abdominal pathology to account for the chylous ascites. Ultimately, after a prolonged hospital course and extended recovery, the patient returned home. Subsequent outpatient follow-up failed to reveal a cause of his necrotizing pancreatitis.