C A S E RE P O R T

Milky Mesentery: Acute with Chylous

AAKANKSHA GOEL, MANISH KUMAR GAUR AND PANKAJ KUMAR GARG From Department of , 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, , 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 , 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 . 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, 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, , 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.

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INDIAN PEDIATRICS 910 VOLUME 55__OCTOBER 15, 2018