Postoperative Chylous Ascites

1Cooper University Hospital, Camden, NJ

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 361

Case Presentation:

A 65‐year‐old woman presented with progressive abdominal distension for 2 months. It started after she underwent nephrectomy for left‐sided renal cell carcinoma, followed by splenectomy for injury sustained during nephrectomy. She noticed abdominal distension soon after surgery, which slowly worsened. On physical examination, the patient had a distended, nontender abdomen without masses. Computed tomography (CT) of the abdomen showed ascites. Cytology of the ascitic fluid was negative for malignant cells. Serum‐ascites albumin gradient (SAAG) was 0.5; therefore, portal hypertension related as‐cites was low on the differential. Other causes of nonportal hypertension–related ascites were ruled out. Postoperative lymphatic leak was then thought of as a possible cause of this ascites, as symptoms started soon after surgery. Repeat paracentesis revealed a triglyceride level of 2135 (normal, < 150). Hence, chylous ascites due to a postoperative lymphatic leak was the most probable cause. Patient was managed medically at first. A previously established treatment regimen with cure rate of 90% for postoperative lymphatic leak was followed. The protocol includes a low‐fat diet with medium‐chain triglycerides (MCT) oil supplements for 4–6 weeks. Then the patient is kept nothing by mouth and nourished with total parenteral nutrition. Somatostatin infusion followed by sclerosing agent injection performed by inter‐ventional radiology is the final step. Medical management did not control the chylous ascites, and the patient required multiple therapeutic paracentesis as an outpatient, each time removing more than 4 L of milky white peritoneal fluid. After a few months, she eventually had a peritoneovenous shunt placed to achieve control of the ascites.

Discussion:

Previous studies have demonstrated that chylous ascites (peritoneal fluid rich in triglycerides), is an uncommon finding. Abdominal malignancies and cirrhosis are responsible for the majority of cases in the United States. Some of the rare causes of chylous ascites are postoperative, inflammatory, and congenital. Postoperative chylous ascites occurring within a week usually is a result of damage to the lymphatic vessels. It can also occur several weeks or months after surgery because of adhesion formations or extrinsic compression of lymphatic vessels. Multiple types of surgeries put a patient at risk for injury to the lymphatic vessels including retroperitoneal lymph node dissection, catheter placement for peritoneal dialysis, and abdominal aneurysm repair. Patients who present with ascites postoperatively should have their peritoneal fluid tested for triglycerides, as this helps confirm the diagnosis.

Conclusions:

A patient presenting with ascites in the immediate postoperative period should have peritoneal fluid evaluated for chylous ascites. If chylous ascites is noted, medical therapy should be attempted first. Patients not responding to medical therapy may require a peritoneovenous shunt.

Disclosures:

M. Patel ‐ none; P. Shivaprasad ‐ none; J. Young ‐ none

To cite this abstract:

Patel M, Shivaprasad P, Young J. Postoperative Chylous Ascites. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 361. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/postoperative-chylous-ascites/. Accessed July 19, 2019.

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