A 59-year-old woman with hypertension presented to the emergency department with abdominal pain secondary to gallstone pancreatitis. She had no history of liver disease, tuberculosis, or cancer. She was febrile to 38.9°C (102°F), blood pressure 49/29 mm Hg, heart rate 124 beats per minute, respiratory rate 31 breaths per minute, and normal oxygenation. Abdominal computed tomography showed pancreatic head necrosis and a large pseudocyst. The patient was stabilized and underwent computed tomography-guided drainage of the pseudocyst and later was discharged to a rehabilitation facility with a nasojejunal tube and intermittent tube feeds.
Over the next 4 weeks, she developed worsening abdominal distention and failed multiple attempts to advance her diet. Repeat imaging revealed development of a 13.5 × 5.3-cm segment of walled-off necrosis and extensive ascites (Figure 1). A diagnostic and therapeutic paracentesis yielded 2.4 L of milky ascites (Figure 2). Fluid analysis showed an elevated triglyceride level of 1014 mg/dL, cell count of 583 cells/μL with lymphocytic predominance (neutrophils 3%, lymphocytes 96%), and a serum-ascites albumin gradient of 1.3 g/dL. Gram stain and ascites fluid cultures were negative.
Endoscopy revealed that the pseudocyst caused significant narrowing of the duodenum, necessitating cystogastrostomy and jejunostomy placement to relieve the gastric outlet obstruction and to optimize nutrition. Suspecting impaired lymphatic drainage, her nutrition was switched from a formula high in triglycerides (35% kilocalories from fat) to a 100% amino acid formula (3% kilocalories from fat). Over the next 3 weeks, a decrease in ascitic triglyceride content to 227 mg/dL was noted, but due to poor feeding tube tolerance, she was transitioned to parenteral nutrition. Switching to a triglyceride-free formula mitigated the ascites; however, she occasionally requires therapeutic paracentesis.
Discussion
Chylous ascites is caused by disruption in the abdominal lymphatic system by trauma or obstruction. It presents as progressive, painless abdominal distention over weeks to months, and clinical features include nausea, early satiety, fevers, chills, night sweats, and malnutrition. Worldwide, the most common etiologies are abdominal malignancy, cirrhosis, and tuberculosis. It is an unusual complication of pancreatitis1 and abdominal surgeries and is associated with a 1-year mortality of up to 71%.2
To read this article in its entirety please visit our website.
-Michael A. Santos, MD, Pulkit S. Bose, MS-IV, Sarah Maher, MD, Meeta Desai, MD
This article originally appeared in the April 2017 issue of The American Journal of Medicine.
