A 76 y.o woman comes in two weeks after peritoneal dialysis catheter placement. She has no abdominal pain

she states they could not use the catheter because “milk” is coming out.

what happened? what needs to be done

Our patient had chylous ascites without infection.  Chylous ascites is defined as milky triglyceride-rich peritoneal fluid in the abdominal cavity. It occurs due to the rupture of lymphatics due to obstruction or trauma.  Once this ascites is present in the peritoneum; it is lost to the body so dehydration, electrolyte imbalance,immune suppression and malabsorption can occur.

As you remember, the long-chain triglycerides in the diet are absorbed as chylomicrons  following conversion into fatty acids and triglycerides  in the small intestine.  High triglycerides can be measured in chylous ascites.

CAUSES OF CHYLOUS ASCITES

Trauma/surgery-  fistulas can develop between the lymphatic system and the retroperitoneum.

Inflammatory/infectious- tuberculosis and filariasis are more common in eastern countries. In Tbc, large lymph nodes can obstruct lymphatic drainage.

Malignant- tumors can obstruct the lymphatic flow from the gut to the cisterna chyli causing dilated lymphatics which eventrually rupture.

Congenital- lymphangectasia is the most common cause of chylous ascites in children .

Drugs  Methimazole has been reported to cause chylous ascites along with  tyrosine kinase inhibitors.

But what about of the lymphatic system in the chest?.  An obstruction can occur in the chest as well. Even chf can cause chylous ascites, from increased pressure in the venous system. Lung cancer and goiters have also been reported as causing chylous ascites.

The image above is a pulmonary cause of chylous ascites. The pt had LAM ( lymphangioleiomyomatosis), a disease with muscle proliferation in lymphatics. She underwent a lung transplant but because of her disease, lymphatic drainage was impaired.

Our patient was discharged home. It is not yet clear if the condition will recur.

Browse N, Wilson N, Russo F, et al. Aetiology and treatment of chylous ascites. Br J Surg 1992 Nov;79(11) :1145-50.

Wang X, Zheng Z, Chen M, et al. Chylous ascites has a higher incidence after robotic surgery. Chin Med J.  online  23 December 2021

Dougan M, Anderson M , Abramson J, et al. Case 14-2022: A 57 year-old man with chylous ascites.  N Engl J Med 2022;386:1834-44.

 Elshikh M, Moawad A, Salem U, et al. Oncologic imaging of the lymphatic system: current perspective with multi-modality imaging and new horizon. 2021 Cancers. 13.4554. 10.3990/cancers13184554

Khoury T, Schneider R.  Chylous ascites:a rare adverse effect of methimazole treatment for Grave’s disease—a case report and review of the literature. Case Rep Endocrinol 2015;2015:649303.

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