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Milky Mesentery: Acute Abdomen with Chylous Ascites

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Milky Mesentery: Acute Abdomen with Chylous Ascites C A S E RE P O R T Milky Mesentery: Acute Abdomen with Chylous Ascites AAKANKSHA GOEL, MANISH KUMAR GAUR AND PANKAJ KUMAR GARG From Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi, India. Correspondence to: Dr Aakanksha Background: Clinical presentations of intestinal lymphangiectasia include pitting edema, Goel, House No 1 Sukh Vihar, chylous ascites, pleural effusion, diarrhea, malabsorption and intestinal obstruction. Case Delhi 110 051, India. Characteristics: An 8-year-old male child presented to the emergency department with [email protected] clinical features of peritonitis, raising suspicion of appendicular or small bowel perforation. Intervention/Outcome: Diagnosis of chylous ascites with primary intestinal Received: July 21, 2017; lymphangiectasia made on laparotomy. Message: Acute peritonitis may be a presentation Initial Review: December 26, 2017; of primary intestinal lymphangiectasia and chylous ascites. Accepted: May 24, 2018. Keywords: Acute abdomen, Intestinal lymphangiectasia, Peritonitis. lthough lymphangiectasia is common in the (lymphangiectasia) was made. The chylous fluid was neck and axilla, it rarely involves intra- drained and a thorough peritoneal lavage was done. abdominal organs [1]. Intestinal Biopsies were taken from the mesenteric lymph nodes and Alymphangiectasia is characterized by peritoneum. dilatation of intestinal lymphatics [2,3]. The clinical Histopathological report was negative for tuberculosis presentations of intestinal lymphangiectasia include and malignancy. The ascitic fluid was rich in triglycerides pitting edema, chylous ascites, pleural effusion, diarrhea, (254 mg/dL) and demonstrated chylomicrons and malabsorption and intestinal obstruction. Acute lymphocytes on biochemical analysis. Culture and gram peritonitis is a rare presentation, and it may mimic other stain were negative. Serum LDL, HDL and triglyceride surgical pathologies [4,5]. values were normal. The postoperative period was CASE REPORT uneventful. The abdominal drain was removed on post- operative day 2 with no significant output. He was An 8-year-old male child presented to the emergency discharged on a high protein and low fat diet, and was department with periumbilical pain, vomiting and fever. asymptomatic at 1-year post-surgery follow up. There was no history of tuberculosis or typhoid fever, and no history of trauma or surgery. On examination, he was DISCUSSION febrile with temperature of 39°C. The abdomen was Intestinal lymphangiectasia is classified as primary or distended with diffuse tenderness and guarding. The total leucocyte count was 22,500/mm3. Serum amylase was 23 units/L. Ultrasonography revealed a multiloculated intra- abdominal collection. The presence of severe pain and fever accompanied with clinical features of peritonitis, and sonological evidence of abdominal collection raised the suspicion of appendicular or small bowel perforation with sepsis. X-Ray of the chest and abdomen were unremarkable, there was no evidence of free intra- peritoneal air. In the absence of availability of emergency computed tomography scan, the patient was taken up for emergency laparotomy for the acute abdomen. Laparotomy revealed 150 ml of milky white ascitic fluid and chalky white plaques in the mesentery. A few mesenteric lymph nodes were seen (Fig. 1). The small bowel and the FIG. 1 Chalky white plaques in mesentery due to dilated appendix appeared grossly normal. A clinical diagnosis of lymphatics (bold arrow). Normal fatty yellow mesentery (lined chylous ascites with dilated mesenteric lymphatics arrow). INDIAN PEDIATRICS 909 VOLUME 55__OCTOBER 15, 2018 GOEL, et al. CHYLOUS A SCITES secondary, based on the underlying etiology. Primary with poor weight gain, hypoproteinemia and abdominal intestinal lymphangiectasia represents a congenital distension, elective surgical treatment to treat the disorder of mesenteric lymphatics, whereas secondary is lymphatic fistula is indispensible. Preoperative associated with diseases like constrictive pericarditis, lymphangiography or lymphoscintigraphy is helpful in lymphoma, pancreatitis, trauma, intestinal malignancy, or identifying the anatomical location of the leakage or the may be acquired after surgery [6]. Intestinal presence of a fistula in such presentations [8]. In our case, lymphangiectasia is often associated with chylous ascites the diagnosis of primary intestinal lymphangiectasia was which may easily be mistaken as purulent fluid. The most established by the presence of chylous ascites (rich in common cause of chylous ascites in the pediatric triglycerides and chylomicrons), and the classical population is congenital lymphatic malformation, others appearance of white chalky mesentery in the absence of being malignancy, tuberculosis, trauma, cirrhosis and any secondary cause. post-surgery [7]. The principal mechanisms for formation Contributors: All authors have designed, contributed and of chylous ascites are related to disruption of the approved the manuscript. lymphatic system, from any cause. Funding: None, Competing interest: None stated. Dietary long-chain triglycerides are converted into REFERENCES monoglycerides and free fatty acids and absorbed as 1. Pandey D, Garg PK, Jana M, Sharma J. Retroperitoneal chylomicrons in the small bowel lymphatic system, which lymphangiectasia. ANZ J Surg. 2016;86:517-8. is responsible for high triglyceride content and the milky 2. Isa HM, Al-Arayedh GG, Mohamed AM. Intestinal appearance of lymph. Medium chain triglycerides, lymphangiectasia in children. Saudi Med J. 2016;37:199- constituting approximately one-third of dietary fat, on the 204. other hand, are absorbed directly by the portal venous 3. Rashmi MV, Murthy BN, Rani H, Kodandaswamy CR, system, which is the rationale for their use in the Arava S. Intestinal lymphangiectasia - a report of two conservative management of chylous ascites [7]. cases. Indian J Surg. 2010;72:149-51. 4. Fang F, Hsu S, Chen C, Chen T. Spontaneous chylous Loss of chyle into peritoneal cavity can lead to serious peritonitis mimicking acute appendicitis/ : A case report consequences because of the loss of essential proteins, and review of literature. World J Gastroenterol. lipids, immunoglobulins, vitamins, electrolytes, and water. 2006;12:154-6. In most cases, patients respond to low fat and high protein 5. Vettoretto N, Odeh M, Romessis M, Pettinato G, Taglietti diet, enriched with medium-chain fatty acids and no L, Giovanetti M. Acute abdomen from chylous peritonitis: surgery is required. It is very important to replenish fluid Case report and literature review. Eur Surg Res. 2008;41:54-7. and electrolyte losses and treat vitamin deficiencies [4]. 6. Suresh N, Ganesh R, Sankar J, Sathiyasekaran M. Primary Emergency exploratory laparotomy is mostly done only in intestinal lymphangiectasia. Indian Pediatr. 2009;46:903-6. cases with acute chylous peritonitis for a preoperative 7. Al-busafi SA, Ghali P, Deschênes M, Wong P. Chylous suspicion of bowel perforation; however, it gives the ascites: Evaluation and management. ISRN Hepatol. opportunity to evacuate the peritoneal fluid, wash the 2014;2014:240473. abdominal cavity, and in certain cases, treat the cause. 8. Campisi C, Bellini C, Eretta C, Zilli A, Rin E da, Davini D, et al. Diagnosis and management of primary chylous ascites. J In case of chronic or debilitating ascites associated Vasc Surg. 2006;43:1244-8. INDIAN PEDIATRICS 910 VOLUME 55__OCTOBER 15, 2018.
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