S3631 The Milky Way

Abstract

Introduction: Chylous ascites is a rare clinical finding indicative of peritoneal fluid containing lymphatic drainage. It is characterized by having a milky appearance that is rich in triglycerides, surpassing 110 mg/dL. This condition develops after disruption of the lymphatic system, usually secondary to trauma after abdominal surgery, malignancy, or cirrhosis. Chylous ascites accounts for less than 0.5% of cases of ascites in cirrhotic patients, presenting as progressive and painless abdominal distention. Case Description/Methods: Case of a 71 year-old male with history of cirrhosis due to hepatitis C on remission treated with elbasvir/grazoprevir, hypertension and end stage renal disease (ESRD) on hemodialysis (HD) who came to our institution after developing worsening abdominal distention with associated shortness of breath since 2 weeks prior. He denied fever, chills, cough, palpitations, chest pain, abdominal pain, hematemesis, hematochezia, or melena. Vitals signs were stable and physical exam was remarkable for a distended, tense and painless abdomen. Laboratories showed leukocytes in 7.8 x 103/uL, normocytic-normochromic anemia of 9.0 g/dL and platelets in 262 x103/ uL. Chemistry showed renal function consistent with his ESRD, without electrolyte disturbances. SGPT at 13 U/L and SGOT at 22 U/L. Anti-HBS, HBS ag and HIV ag/ab combo is nonreactive. Abd/pelvic CT scan revealed a nodular liver contour with hypertrophic changes of the left lobe compatible with chronic hepatocellular disease. The patient’s symptoms and findings were consistent with decompensated liver disease with tension ascites, for which a large-volume paracentesis was performed, removing 9L of white-milky fluid with subsequent placement of 50 g of IV albumin. The calculated serum-ascites albumin gradient (SAAG) was 2.4 g/dL consistent with portal hypertension. Ascitic fluid analysis revealed 40 cell count, 2 neutrophils, 916 mg/dL triglycerides and 90 mg/dL cholesterol, indicative of chylous ascites. Discussion: Abdominal paracentesis and analysis of the ascitic fluid are essential for the evaluation and management of chylous ascites. Management should focus on treatment of the underlying disease; however supportive measures may alleviate symptoms. These measures may include repeated paracentesis, diuretic therapy, salt and water restriction and dietary measures. It is imperative to be aware of this unusual manifestation, requiring prompt evaluation and appropriate management of the underlying pathology.Figure 1.: Ascitic fluid obtained after performing abdominal paracentesis.