|Year : 2020 | Volume
| Issue : 2 | Page : 101-104
Acute chylous peritonitis: Report of a case and literature review
MS Alamri1, Raed A Alenezi2, Khulaif K Alanazi2, Mishal M Alrsheedi2, Bassam Z Alshammary2, Hani A Almutair2
1 Department of Surgery, Hail General Hospital, Hail, Saudi Arabia
2 Medical Intern, College of Medicine, University of Hail, Hail, Saudi Arabia
|Date of Submission||26-Jan-2019|
|Date of Acceptance||29-Apr-2019|
|Date of Web Publication||24-Feb-2021|
Dr. Khulaif K Alanazi
Medical Intern, Collage of Medicine, University of Hail, Hail
Source of Support: None, Conflict of Interest: None
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 May 14];8:101-4. Available from: https://www.saudisurgj.org/text.asp?2020/8/2/101/310122
| Introduction|| |
Acute chylous peritonitis is an extensively rare condition; it is the first case described by Renner in 1910 and is defined as the onset of acute abdomen findings due to abrupt chylous fluid accumulation in the peritoneal space., 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. 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|| |
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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The procedure was diagnostic laparoscopic and then converted to laparotomy.
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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Finally, we washed intra-abdominal cavity by two litters of normal saline and fixed 3 intra-abdominal drains.
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|| |
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). 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. 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. 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].,
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.,, Pancreatitis is a rare cause of chylous ascites formation. 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. Most cases involve chronic pancreatitis, though acute pancreatitis has also been recognized as the causative reason, with first such report dating back to 1984. Since then, only a few cases of chylous ascites secondary to acute pancreatitis have been documented. 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. 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., 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.
| Conclusion|| |
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]