S1428 When Ascitic Fluid Changes Color: A Rare Case of Progression From Pancreatic Ascites to Chylous Ascites

Abstract

INTRODUCTION: Chylous ascites is a rare form of ascites due to leakage of lipid-rich lymph into the peritoneal cavity. Pancreatic ascites is not an uncommon form of ascites, resulting from pancreatic duct injury leading to leakage of pancreatic fluid into the peritoneal cavity. Paracentesis is an essential diagnostic tool. While the fluid in chylous ascites has a cloudy appearance and contains high triglyceride levels, the fluid in pancreatic ascites looks opalescent with elevated amylase and lipase levels. We report a case of chronic pancreatitis progressing from pancreatic to chylous ascites. CASE DESCRIPTION/METHODS: A 53-year-old male with a history of an alcohol use disorder, presented with acute worsening abdominal distention and weight loss over three weeks. On physical exam, he had temporal wasting, protuberant abdomen, with massive ascites. Labs showed leukocytosis 46.3 k/uL, serum lipase 1600 U/L, liver enzymes WNL. The suspicion for pancreatic ascites was confirmed by fluid analysis demonstrating amylase >7500 U/L. CT abdomen and MRCP showed dilated and irregular pancreatic duct (Figure 1). EUS revealed a dilated pancreatic duct consistent with chronic pancreatitis (Figure 2). ERCP was done, and a pancreatic stent was placed even though there was no obvious leak. Three weeks after the initial presentation, he returned with worsening abdominal distention. Paracentesis this time revealed milky fluid with elevated triglycerides >2000 mg/dL with amylase <1000 U/L suggesting chylous ascites (Figure 3). Repeat ERCP revealed persistently dilated pancreatic duct with no active contrast extravasation. DISCUSSION: Chylous ascites is a rare condition; Common etiologies include malignancy, cirrhosis, and trauma. Chylous ascites after chronic pancreatitis is a rare event caused by compression of adjacent lymphatics by pancreatic inflammation. The treatment has not been well established and involves correcting the reversible underlying causes and reducing the ascites formation, with dietary modifications (low-fat diet with medium-chain triglycerides [MCTs]), use of somatostatin or octreotide and diuretic therapy. Here we presented a rare case of Chylous ascites that has developed after pancreatic ascites. Since malignancy is the most described etiology, we repeated CT abdomen, and the patient underwent EUS (Figure 2), both negative for any malignancy. To our knowledge, this is the first time a case of chronic pancreatitis being presented as a transition from pancreatic ascites to Chylous ascites.Figure 1.: CT scan (Left panel) and MRI (Right panel) showing dilated pancreatic duct and pancreatic parenchymal changes of chronic pancreatitis.Figure 2.: Endoscopic Ultrasound showing dilated pancreatic duct (green arrow) and pancreatic parenchymal changes consistent with chronic pancreatitis.Figure 3.: Milky ascitic fluid consistent with chylous ascites.