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CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 101-104

Acute chylous peritonitis: Report of a case and literature review


1 Department of Surgery, Hail General Hospital, Hail, Saudi Arabia
2 Medical Intern, College of Medicine, University of Hail, Hail, Saudi Arabia

Date of Submission26-Jan-2019
Date of Acceptance29-Apr-2019
Date of Web Publication24-Feb-2021

Correspondence Address:
Dr. Khulaif K Alanazi
Medical Intern, Collage of Medicine, University of Hail, Hail
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_5_19

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  Abstract 

Acute chylous peritonitis is an extensively rare condition; chylous ascites may result from many pathological conditions, including congenital defects of the lymphatic system, trauma, peritoneal infections, and malignant neoplasms. In most cases, the presence of tenderness and rebound leads the patients to be misdiagnosed with acute appendicitis. In our case, the preoperative diagnosis was perforated acute appendicitis.

Keywords: Acute chylous peritonitis, chyloperitoneum, chylous ascites


How to cite this article:
Alamri M S, Alenezi RA, Alanazi KK, Alrsheedi MM, Alshammary BZ, Almutair HA. Acute chylous peritonitis: Report of a case and literature review. Saudi Surg J 2020;8:101-4

How to cite this URL:
Alamri M S, Alenezi RA, Alanazi KK, Alrsheedi MM, Alshammary BZ, Almutair HA. Acute chylous peritonitis: Report of a case and literature review. Saudi Surg J [serial online] 2020 [cited 2021 Apr 15];8:101-4. Available from: https://www.saudisurgj.org/text.asp?2020/8/2/101/310122


  Introduction Top


Acute chylous peritonitis is an extensively rare condition; it is the first case described by Renner[1] in 1910 and is defined as the onset of acute abdomen findings due to abrupt chylous fluid accumulation in the peritoneal space.[2],[3] A few cases have been presented in the literature. Preoperative diagnosis is difficult due to acute abdomen findings, and acute chylous peritonitis is usually confused with pathologies such as acute appendicitis, organ perforation, ovarian torsion, and pelvic inflammatory disease.[2] In this article, we report a chylous peritonitis case that was admitted with acute abdomen findings and underwent laparoscopy because the etiology could not be fully explained. Diagnosis and treatment approaches are discussed given the current literature.


  Case Report Top


A 32-year-old Saudi male patient presented to the Hospital with complaint of abdominal pain for 3 days associated with constipation, nausea, and vomiting, but no fever. He has a history of chronic gastritis on intermittent oral proton pump inhibitor and used Chin's herbal to decrease a weight 4 years ago. On examination, there was tachycardia but no hypotension or fever. His abdomen was mildly distended with general tenderness and guarding. Rebound sign was positive, and there was no bowel sound.

Laboratory and radiology results

His white blood cell count was 17,000 and Hb was 18%. Plain abdominal X-ray showed insignificant air distribution. Computed tomography scan of the abdomen and pelvis showed moderate free fluid intraperitoneal and peripancreatic and perirenal collection, and there was no evidence of pneumoperitoneum [Figure 1] and [Figure 2].
Figure 1: Abdomen–pelvis computed tomography scan; mild-to-moderate intraabdominal collection, no bowel dilatation

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Figure 2: Abdomen–pelvis computed tomography scan; pelvis collection

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Procedure

The procedure was diagnostic laparoscopic and then converted to laparotomy.

Finding

Milky like intra-abdominal collection about 700ml [Figure 3], the pancreas was congested but no sign of acute pancreatitis, appendix was normal [Figure 4], no colitis or perforated peptic ulcer. After explored the retro-peritoneal; we didn't find active chylous leak. Difficult to identified the abdominal lymphatic trunk.
Figure 3: Intra-peritoneum milk-like collection by diagnostic laparoscopy

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Figure 4: Intra-peritoneum milk-like collection, normal appendix

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Finally, we washed intra-abdominal cavity by two litters of normal saline and fixed 3 intra-abdominal drains.

Postoperation

He doing well, the general condition is improved gradually and no active issue. The patient was on intravenous Human Albumen, antibiotics, and IV fluid replacement. On the first day, we started with IV Octreotide for five days, to reduce gastric-intestinal secretion and motility. The patient was in NPO for six days then advance oral intake gradually (used short and medium-chain fatty acids) to prevent reaccumulating of chylous leak. The patient was kept with three intraabdominal drains; on the first day, it was collected about 150 ml with white to red color, but it increases in the second day to 230 ml for 24 hrs, then after that, it was starting to decrease gradually. On the third day, the color of the drain was changed from whitish to yellowish color, which means stop chylous leak. Two strains were removed in the fifth-day post-surgery and the last one removed in the seventh-day post-surgery at the time of discharge.


  Discussion Top


Chylous ascites is caused by the accumulation of chyle in the peritoneal cavity due to disruption of the lymphatic system. Chylous ascites may be divided into three main categories: True chylous ascites (Fluid with high triglyceride content), Chyliform ascites (Fluid with a lecithin-globulin complex due to fatty degeneration of cells), and Pseudochylous ascites (Fluid that is milky in appearance due to the presence of pus).[4] In our case, the level of triglyceride in the peritoneal fluid was higher than serum triglyceride. For that, we classified our case as true chylous ascites.

Chylous ascites may result from many pathological conditions, including congenital defects of the lymphatic system, trauma, peritoneal infections, and malignant neoplasms.[5] Abdominal malignancy and cirrhosis are the most common cause of chylous ascites in adults in developed countries while developing countries is tuberculosis and filariasis. In children, congenital lymphatic abnormalities account for the majority of cases of chylous ascites.5. Other causes include trauma to the intestines or mesentery, idiopathic retroperitoneal fibrosis, sarcoidosis, and abdominal or pelvic radiation therapy.[6] The resection of an abdominal aortic aneurysm or retroperitoneal lymph node dissection is the most surgical procedures that can result in chylous ascites [Table 1].[7],[8]
Table 1: Causes of chylous ascites

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In most cases, a pain starts suddenly as a cramp and it gradually increases becoming most prominent in the right lower quadrant and the pelvis. Chylous fluid may accumulate in those areas, causing the reported pain. However, the main cause of the pain is the strain from the fluid, especially in the right retroperitoneal area and mesentery, rather than the presence of the chylous fluid per se. In most cases, the presence of tenderness and rebound leads the patients to be misdiagnosed with acute appendicitis.[9],[10],[11] Pancreatitis is a rare cause of chylous ascites formation.[12] It is believed that either lymph may actually leak through destroyed lymphatics due to pancreatic enzyme erosion or that chylous accumulation is the result of exudation of chyle caused by the obstruction of lymphatic channel flow secondary to severe inflammatory changes that take place in the retroperitoneal space surrounding the pancreas.[7] Most cases involve chronic pancreatitis,[13] though acute pancreatitis has also been recognized as the causative reason, with first such report dating back to 1984.[12] Since then, only a few cases of chylous ascites secondary to acute pancreatitis have been documented.[14] In almost all of them, the presence of chyle into the peritoneal cavity was discovered at some time after the episode of pancreatitis usually days or weeks.

Chyloperitoneum is usually discovered during exploratory laparotomy, and in some cases, this is the only intraoperative finding. Negative laparotomies have been reported, in which the underlying cause was never discovered.[15] However, therapeutic choices may vary in accordance with the underlying pathology. Thorough lavage of the abdomen and adequate drainage has proven to be an excellent treatment modality for acute chylous peritonitis since the resolution of chylous ascites usually occurs within the next few days. However, successful conservative treatment has also been reported.[16],[17] This requires proper preoperative diagnosis, which is often difficult due to the exceptional rarity of this pathological condition and its resemblance to other surgical urgencies that call for immediate laparotomy. Long-term fasting supported by total parenteral nutrition offers resolution in many cases. Alternatively, a high-protein and low-fat diet has proven to be efficacious in reducing the amount of chyle produced. Administration of octreotide remains controversial.[7]


  Conclusion Top


Acute chylous peritonitis is an extensively rare condition and should be expected in any patient present with milk-like ascites and signs and symptoms of the acute abdomen. The causes of chylous ascites are unknown.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Renner A. Chylus als bruchwasser beim eingeklemmten bruch. Beitr Klin Chir 1910;70:695-8.  Back to cited text no. 1
    
2.
Vettoretto N, Odeh M, Romessis M, Pettinato G, Taglietti L, Giovanetti M. Acute abdomen from chylous peritonitis: A surgical diagnosis. Case report and literature review. Eur Surg Res 2008;41:54-7.  Back to cited text no. 2
    
3.
Krizek TJ, Davis JH. Acute chylous peritonitis. Arch Surg 1965;91:25362.  Back to cited text no. 3
    
4.
Madding GF, McLaughlin RF, McLaughlin RF Jr. Acute chylous peritonitis. Ann Surg 1958;147:419-22.  Back to cited text no. 4
    
5.
Cárdenas A, Chopra S. Chylous ascites. Am J Gastroenterol 2002;97:1896-900.  Back to cited text no. 5
    
6.
Browse NL, Wilson NM, Russo F, al-Hassan H, Allen DR. Aetiology and treatment of chylous ascites. Br J Surg 1992;79:1145-50.  Back to cited text no. 6
    
7.
Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: A collective review. Surgery 2000;128:761-78.  Back to cited text no. 7
    
8.
Combe J, Buniet JM, Douge C, Bernard Y, Camelot G. Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. Case report with review of the literature. J Mal Vasc 1992;17:151-6.  Back to cited text no. 8
    
9.
Smith EK, Ek E, Croagh D, Spain LA, Farrell S. Acute chylous ascites mimicking acute appendicitis in a patient with pancreatitis. World J Gastroenterol 2009;15:4849-52.  Back to cited text no. 9
    
10.
Fang FC, Hsu SD, Chen CW, Chen TW. Spontaneous chylous peritonitis mimicking acute appendicitis: A case report and review of literature. World J Gastroenterol 2006;12:154-6.  Back to cited text no. 10
    
11.
Lamblin A, Mulliez E, Lemaitre L, Pattou F, Proye C. Acute peritonitis: A rare presentation of chylous ascites. Ann Chir 2003;128:49-52.  Back to cited text no. 11
    
12.
Goldfarb JP. Chylous effusions secondary to pancreatitis: Case report and review of the literature. Am J Gastroenterol 1984;79:133-5.  Back to cited text no. 12
    
13.
Al-Ghamdi MY, Bedi A, Reddy SB, Tanton RT, Peltekian KM. Chylous ascites secondary to pancreatitis: Management of an uncommon entity using parenteral nutrition and octreotide. Dig Dis Sci 2007;52:2261-4.  Back to cited text no. 13
    
14.
Zhang ZY, Howard JM. Chylous ascites. A late complication of massive peripancreatic necrosis. Int J Pancreatol 1997;21:259-61.  Back to cited text no. 14
    
15.
Weichert RF, Jamieson CW. Acute chylous peritonitis. A case report. Br J Surg 1970;57:230-2.  Back to cited text no. 15
    
16.
Khan FY, Matar I. Chylous ascites secondary to hyperlipidemic pancreatitis with normal serum amylase and lipase. World J Gastroenterol 2007;13:480-2.  Back to cited text no. 16
    
17.
Thompson PA, Halpern NB, Aldrete JS. Acute chylous peritonitis. J Clin Gastroenterol 1981;3 Suppl 1:51-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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