Colon signet-ring cell carcinoma with chylous ascites caused by immunosuppressants following liver transplantation: A case report.

BACKGROUND: Chylous ascites is caused by disruption of the lymphatic system, which is characterized by the accumulation of a turbid fluid containing high levels of triglycerides within the abdominal cavity. The two most common causes are cirrhosis and tuberculosis, and colon signer ring cell carcinoma (SRCC) due to the use of immunosuppressants is extremely rare in cirrhotic patients after liver transplantation, making it prone to misdiagnosis and missed diagnosis. CASE SUMMARY: A 52-year-old man who underwent liver transplantation and was administered with immunosuppressants for 8 months was admitted with a 3-month history of progressive abdominal distention. Initially, based on lymphoscintigraphy and lymphangiography, lymphatic obstruction was considered, and cystellar chyli decompression with band lysis and external membrane stripping of the lymphatic duct was performed. However, his abdominal distention was persistent without resolution. Abdominal paracentesis revealed allogenic cells in the ascites, and immunohistochemistry analysis revealed adenocarcinoma cells with phenotypic features suggestive of a gastrointestinal origin. Gastrointestinal endoscopy was performed, and biopsy showed atypical signet ring cells in the ileocecal valve. The patient eventually died after a three-month follow-up due to progression of the tumor. CONCLUSION: Colon SRCC, caused by immunosuppressants, is an unusual but un-neglected cause of chylous ascites.

A Case of Cancer of Unknown Primary Presenting with Chylothorax.

A 56-year-old man presented to our hospital with dyspnea on exertion for two months. Bilateral pleural effusions were found, and a close examination revealed a chylothorax, including adenocarcinoma. The primary tumor could not be identified by systemic examination. Therefore, the patient was diagnosed with cancer of unknown primary origin (CUP) presenting with chylothorax. Chemotherapy was administered for CUP, and thoracentesis, pleurodesis, ascites puncture, and nutritional therapy were performed for chylothorax and chylous ascites. Although drainage frequency and tumor marker levels (CA19-9, DUPAN-2, and Span-1) temporarily decreased, disease control deteriorated, and the patient died 12 months after the initial diagnosis.

Primary chylous peritonitis: a rare case report from Syria.

Introduction and importance: Chylous peritonitis is characterized by a sudden accumulation of chyle in the peritoneal cavity, leading to symptoms of an acute abdomen. This condition is quite rare, with less than 100 cases documented in the medical literature, and is often misdiagnosed. Case presentation: The authors present a case of an acute abdomen in a young man who was initially suspected to have a perforated peptic ulcer. After laparotomy, the diagnosis of chylous peritonitis was confirmed. Despite extensive investigations, no underlying cause was identified. Treatment involved peritoneal lavage and placement of a pelvic drainage tube, with discharge after three days on a low-fat. Clinical discussion: Chylous peritonitis is a relatively rare condition, occurring in ~1 in 20 000 individuals. Chyle leakage can be detected through various diagnostic modalities including ultrasound, computed tomography, laparoscopy, or exploratory laparotomy. In cases where a definitive etiology is not identified, treatment typically involves peritoneal lavage and drainage. Postoperative management focuses on a low-fat diet and somatostatin administration to prevent recurrence. Conclusion: The present case highlights the importance of considering primary chylous peritonitis as a potential cause of acute abdomen in young patients. Future research should focus on identifying risk factors and establishing evidence-based guidelines for approaching this condition.

Bilateral Renal Vein Thrombosis and Chylous Ascites in Phospholipase A2 Receptor-Associated Membranous Nephropathy: A Case Report.

Phospholipase A2 receptor (PLA2R)-associated membranous nephropathy is an important cause of nephrotic syndrome that can lead to a variety of systemic manifestations. Chylous ascites and bilateral renal vein thrombosis are rare manifestations in adult nephrotic syndrome, and there have been no reported cases demonstrating both chylous ascites and bilateral renal vein thrombosis in patients with PLA2R-associated membranous nephropathy. Here, we report the first case of PLA2R-associated membranous nephropathy complicated by renal vein thrombosis and chylous ascites successfully treated with anticoagulation and rituximab. A 65-year-old African American male presented with abdominal pain for four days, hematochezia for one day, and lower extremity edema for one year. Blood pressure was 158/73 mmHg and other vital signs were normal. Physical examination revealed abdominal distention, periumbilical tenderness, and bilateral lower extremity edema. Laboratory analysis showed high serum creatinine, hypoalbuminemia, hyperlipidemia, and proteinuria on 24-hour urine chemistry, all consistent with nephrotic syndrome. Abdominal computed tomography scan demonstrated nonocclusive bilateral renal vein thrombosis with ascites. Paracentesis revealed chylous ascites. Continuous heparin infusion was started for thrombosis. Esophagoduodenoscopy and colonoscopy did not reveal a source of bleeding. Serum anti-PLA2R was found positive, suggesting membranous nephropathy. Rituximab, along with warfarin switched from heparin, successfully controlled disease activity. Chylous ascites in nephrotic syndrome is thought to be associated with bowel edema. In our case, we hypothesize that renal vein thrombosis caused lymphatic fluid leakage by increasing lymphatic pressure. The case illustrates the importance of considering membranous nephropathy as a cause of chylous ascites and renal vein thrombosis. Development of lymphatic imaging techniques is warranted to clarify the pathophysiology.

Examination of the Usefulness of Standby Therapy for Refractory Chylous Ascites After Multiple Lymphangiography Interventions.

Chylous ascites is infrequently observed following lymph node dissection in surgeries for gynecological malignancies. If symptoms develop, they can severely debilitate patients and increase the risk of infection, particularly those with a low performance status following the primary operation. Treatment of chylous ascites is often challenging and protracted, with no treatment currently guaranteeing a complete cure. This study explores the efficacy of standby therapy for refractory chylous ascites in a 46-year-old woman with gynecological malignancies who did not respond to multiple lymphangiographic interventions. Due to a suspicion of left ovarian cancer, she underwent surgery including lymph node dissection. On the following day, significant amounts of ascites were confirmed in the abdominal cavity. Despite performing lymphangiography twice, the chylous ascites persisted. During follow-up in the outpatient ward, on the 142nd post-surgery day, the ascites had spontaneously resolved. In cases like this, where symptoms are relatively mild and surgical intervention is not preferred due to complications or patient preference following lymphangiography, it may be beneficial to use standby therapy in combination with dietary management during outpatient follow-up. Such an approach could yield medium- to long-term improvements and should be considered. However, if further treatment is planned following the initial surgery, the patient's long-term prognosis should be considered, and treatment should be administered promptly. Various methods exist for treating refractory chylous ascites, including expectant therapy, dietary management, percutaneous drainage, lymphangiography and embolization, and surgical lymphatic ligation. Tailoring individualized treatment plans for each patient and pursuing a multidisciplinary approach is advisable. Although initiating adjuvant chemotherapy may not be feasible, long-term standby therapy is beneficial, even if lymphangiography proves ineffective in the short term.

Delayed chylous fluid leakage at the surgical site following thoracic corpectomy via a lateral extracavitary approach: illustrative case.

BACKGROUND: Chylous fluid leakage following spinal surgery is a rare and potentially difficult-to-manage complication that can lead to wound complications, pain, or nutritional deficiencies. Although the thoracic duct is localized near the thoracic spine, reports of thoracic duct injuries secondary to posterior thoracic spine surgery are rare. OBSERVATIONS: The authors present the case of a 57-year-old male with a known history of metastatic renal cell carcinoma to the thoracic spine who had undergone a thoracolumbar fusion with thoracic corpectomy and presented with concern for a chyle leak almost a year after his surgery. The patient had a complicated oncological history and underwent decompression and fusion to treat his significant thoracic metastatic disease. A year later, he presented with back pain and a significant fluid collection at the surgical site, which was drained and found to be consistent with chyle. The patient was treated conservatively, and imaging of the thoracic duct a few months later demonstrated no direct injury, likely indicating either transient injury or potential obstruction of the thoracic duct from metastatic disease. LESSONS: This case demonstrates a rare, potential complication when treating extensive thoracic metastatic disease as well as the workup and potential treatments when facing thoracic duct injury. https://thejns.org/doi/10.3171/CASE24280.

Acute primary chylous peritonitis mimicking acute abdomen: a case report and literature review.

Acute chylous peritonitis is an uncommon medical condition that can occur suddenly, resulting in the buildup of chylous fluid in the peritoneal cavity. It is considered idiopathic because the exact cause is often unknown. The symptoms of acute chylous idiopathic peritonitis can mimic other abdominal emergencies, making it challenging to diagnose and manage, requiring a multidisciplinary approach. We present a case report of acute idiopathic chylous peritonitis miming acute abdomen, how was successfully treated with surgery, and provide a comprehensive review of the available literature on this topic. Chylous peritonitis is a rare condition whose clinical presentation mimics an acute abdomen. It is necessary to undertake careful exploration. An emergent laparotomy is indicated to treat the peritonitis and search for and treat the underlying cause.

Left Chylothorax Without Ascites in a Liver Transplant Patient.

Chylothorax is a rare condition that results from thoracic duct disruption with malignant and nonmalignant etiologies manifesting as a pleural effusion. Typically, chylothorax in the setting of cirrhosis is associated with the migration of chylous ascites. We present the case of a 64-year-old male with prior liver transplant who presented with new-onset transudative chylothorax without chylous ascites who responded to transjugular intrahepatic portosystemic shunt revision, diuresis, and serial thoracentesis.

Lymphatic Interventions in Congenital Heart Disease.

Lymphatic disorders in congenital heart disease can be broadly classified into chest compartment, abdominal compartment, or multicompartment disorders. Heavily T2-weighted noninvasive lymphatic imaging (for anatomy) and invasive dynamic contrast magnetic resonance lymphangiography (for flow) have become the main diagnostic modalities of choice to identify the cause of lymphatic disorders. Selective lymphatic duct embolization (SLDE) has largely replaced total thoracic duct embolization as the main lymphatic therapeutic procedure. Recurrence of symptoms needing repeat interventions is more common in patients who underwent SLDE. Novel surgical and transcatheter thoracic duct decompression strategies are promising, but long-term follow-up is critical and eagerly awaited.

Case report: Chylopericardium secondary to dialysis catheter related jugular venous thrombosis in two dogs receiving long-term hemodialysis.

Chylopericardium is a rare entity in veterinary medicine. In this report we document the development of chylopericardium in two dogs undergoing chronic hemodialysis. An 11-year-old female spayed Labrador retriever (Case 1) presented with acute coughing and lethargy 2 months following initial dialysis catheter placement and initiation of dialysis therapy for severe azotemia. Echocardiography demonstrated severe pericardial effusion and cardiac tamponade. Pericardial fluid analysis was consistent with chylous effusion. The dog underwent a subtotal pericardiectomy with thoracic duct ligation, and a PleuralPort™ was placed. The patient continued to receive outpatient hemodialysis therapy after pericardiectomy for several months until she died acutely at home. A 4-year-old male neutered Doberman (Case 2) was being treated for 2 months with outpatient hemodialysis for management of chronic kidney disease. On presentation for the 17th hemodialysis treatment, the patient had increased respiratory rate. Echocardiography demonstrated pleural and pericardial effusions, and fluid analysis in both cavities was consistent with chylous effusion. Use of tissue plasminogen activator (TPA), clot removal and replacement of the catheter was attempted; however pleural and pericardial effusion continued. The patient was euthanized after 25 hemodialysis sessions as owners elected not to pursue more procedures. In both cases, the cause of the chylopericardium was suspected to be secondary to catheter-associated thrombosis and/or stenosis based on multiple imaging modalities. Despite use of rivaroxaban and clopidogrel concurrently in each case, the chylous effusion persisted. This case report describes clinical details of a rare complication of long-term indwelling dialysis catheters in two dogs.

Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature.

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Post-Traumatic Chylous Wrist Effusion: A Case Report.

Chylous joint effusion is a rare condition characterized by the presence of a milky, viscous synovial fluid with abnormal lipid concentrations. The thorax is the most common site of involvement. Only a handful of cases have been reported in the field of orthopedic surgery and even fewer have been reported involving uncommon locations such as the knee. Treatment of chylous joint effusion may require surgical intervention along with the use of somatostatin or octreotide and a low-fat diet. We present herein a case of post-traumatic chylous effusion in the wrist treated with surgical incision and drainage, octreotide, and a low-fat diet. There have been few reports of chylous effusion in the knee; however, to our knowledge, this is the first report of post-traumatic chylous effusion in the wrist.

Chylous ascites after associating liver partition and portal vein ligation for stage hepatectomy (ALPPS): overview and case report.

Chylous ascites is an uncommon pathology with low incidence following hepato-pancreato-biliary surgery, there are no cases reported in the international literature following the associating liver partition and portal vein ligation for stage hepatectomy (ALPPS) procedure. It is caused by abnormal intraperitoneal accumulation of lymph fluid in the abdominal cavity secondary to obstruction or injury to the chyle cistern or its tributaries. We describe the case of a 49-year-old woman diagnosed with colon cancer and liver metastasis. ALPPS was performed, on a first and second stage, presenting a high drainage output as well as change in the characteristics of the drainage fluid. The diagnosis of chylous ascites was confirmed by finding triglyceride levels in the drainage fluid at 300 mg/dL. Medical treatment was started based on a hyper-protein diet and fat restriction, supplemented with medium-chain triglycerides and somatostatin analog, with fistula resolution. It can be managed with medical treatment.

Chylous leakage after esophagectomy for esophageal cancer: a systematic review.

BACKGROUND: Chylous leakage is a rare complication following esophagectomy; however, it can lead to mortality. We aimed to systematically evaluate the factors that may lead to increased chylous leakage after esophagectomy. METHODS: Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for all studies investigating the occurrence of chylous leakage after esophagectomy. RESULTS: A total of 32 studies were identified, including 26 randomized controlled trials and 3 cohort and case-control studies, each. The overall incidence of chylous leakage was 4.7% (278/5,971 cases). Analysis of preoperative, intraoperative, and postoperative factors showed that most of the qualitative analysis results did not significantly increase the incidence of chylous leakage. In some quantitative analyses, the chylous leakage rate was significantly lower in the thoracic duct mass ligation group than in the conservative treatment group (relative risk [RR] = 0.33; 95% confidence interval [CI], 0.13-0.83; I2 = 0.0%; P = 0.327). Direct oral feeding significantly reduced chylous leakage compared with jejunostomy (RR = 0.06; 95% CI 0.01-0.33; I2 = 0.0%; P = 0.335). However, preoperative inspiratory muscle training (RR = 1.66; 95% CI, 0.21-12.33; I2 = 55.5%; P = 0.134), preoperative chemoradiotherapy (RR = 0.99; 95% CI, 0.55-1.80; I2 = 0.0%; P = 0.943), and robotic assistance (RR = 1.62; 95% CI, 0.92-2.86; I2 = 0.0%; P = 0.814) did not significantly reduce the incidence of chylous leakage. CONCLUSIONS: Ligation of the thoracic duct and direct oral feeding can reduce the incidence of chylous leakage after esophagectomy in patients with esophageal cancer. Other contributing factors remain unclear and require validation in further high-quality studies.

Successful management of chylous ascite after removal of residual mass in non-seminomatous germ cell tumours following chemotherapy: A single-center experience and review of the literature.

INTRODUCTION: Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. CASE PRESENTATION: We hereby present the case of a 20-year-old man who had undergone RPLND with complete surgical excision. A lesion of the Cisterna chyli complicated the operation. The post-operative course was marked by the appearance of chylous ascites. The conservative management strategy for this complication was successful, but only after a month. CLINICAL DISCUSSION: Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. Conservative management based on a high-protein diet with fat restriction and medium-chain triglyceride supplementation, and somatostatine are usually successful. Surgery should be reserved for situations that are refractory to treatment. CONCLUSIONS: We report our successful management and, we also analysed the different management protocols using our experience and review of the literature.

Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites.

We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.

Successful Treatment of Refractory Chylous Ascites With Octreotide in a Patient With Decompensated Cirrhosis.

Chylous ascites is a rare manifestation of decompensated cirrhosis that is associated with increased short-term mortality. Exclusion of other etiologies must be performed to allow for appropriate management, which itself can be a challenge in the setting of decompensated cirrhosis. We report a case of chylous ascites in a patient with decompensated cirrhosis that was successfully managed with octreotide before liver transplantation.

Management of Idiopathic Infantile Chylous Ascites.

Chylous ascites is the accumulation of triglyceride-rich lymphatic fluid in the peritoneal cavity. We present the case of a four-month-old male admitted for abdominal distension. A large volume of ascites was confirmed by imaging. Paracentesis indicated chylous aspirate and drainage was performed using a pigtail catheter. Total parenteral nutrition was initiated and fluconazole prophylaxis was implemented for seven days. Twenty-six days after admission, abdominopelvic magnetic resonance imaging showed trace ascites but no signs of lymphatic malformation. He began transitioning to nasogastric feeds with plans to eventually resume oral feeds. This case not only highlights the limitations in our abilities to definitively identify the etiology of pediatric chylous ascites but also demonstrates how chylous ascites management can carefully combine conservative and surgical strategies to optimize patient outcomes.

Incidence and Risk Factors for Chyle Leaks After Neuroblastic Tumor Resection: A Systematic Review of Published Studies.

BACKGROUND: Chyle leakage/ascites after surgical resection of neuroblastic tumors may delay the start of chemotherapy and worsen prognosis. Previous studies have reported a highly variable incidence and risk factors remain largely unknown. This study aims to analyze the true incidence of chyle leaks and ascites and seeks to identify risk factors and optimal treatment strategies. METHODS: Medline/Embase databases were searched according to PRISMA guidelines. Literature reviews, case reports, and non-English papers were excluded. Data were extracted independently following paper selection by 2 authors. RESULTS: The final analysis yielded 15 studies with N = 1468 patients. Chylous ascites was recorded postoperatively in 171 patients (12%). Most patients experiencing chyle leaks were successfully treated conservatively with drainage, bowel rest, parenteral nutrition and octreotide with variable combinations of these treatment options. 7/171 (4%) patients required operative exploration to control troublesome persistent chyle leaks. In risk factor analysis, higher tumor stage was significantly associated with the risk of chyle leak (P < 0.0001) whereas no correlation was observed with adrenal vs non-adrenal tumor location, INRG risk groups and tumor laterality. CONCLUSION: Chyle leakage after surgery for neuroblastic tumors is a common morbid complication occurring in some 12% of patients. Higher INSS tumor stage portends greater risk(s). Conservative therapy strategies appear successful in the majority of cases. To avert this complication meticulous mesenteric lymphatic ligation is recommended especially for those patients with higher tumor stage(s) requiring extensive radical surgery including retroperitoneal lymph node resection. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Systematic review.

Chylous Ascites Associated with Advanced Pancreatic Cancer That Improved with Appropriate Treatment: A Case Report.

Chylous ascites is a rare form of ascites with high triglyceride content arising from the thoracoabdominal lymph nodes in the peritoneal cavity due to various benign or malignant etiologies, including pancreatic cancer. During cancer chemotherapy, the accumulation of ascites can lead to the deterioration of the patient's general condition, making chemotherapy administration difficult, and resulting in a poor prognosis. We encountered a rare case of chylous ascites complicated by advanced pancreatic cancer. The patient presented with a discrepancy between the shrinkage of the pancreatic cancer and the accumulation of ascites. Therefore, we were able to promptly diagnose chylous ascites by performing biochemical tests. The patient was treated with octreotide, reportedly effective in treating chylous ascites, which rapidly improved the chylous ascites and general condition of the patient, allowing the patient to continue chemotherapy for pancreatic cancer. Therefore, physicians should consider the possibility of chylous ascites when clinically unexplained ascites are observed in patients with advanced cancer. The investigation and treatment of chylous ascites should be initiated as soon as possible.