This document presents a case of chylous ascites. It defines chylous ascites as triglyceride levels greater than 1.24 mmol/L and discusses potential causes including malignancy (2/3 of cases), pancreatitis, postoperative disruption of lymphatics, and carcinoid tumors. For this specific case, imaging found small mesenteric nodes, abnormal soft tissue in the right iliac fossa, and a pancreatic pseudocyst. Lymphoscintigraphy and tumor markers were discussed as further diagnostic tests. Conservative management includes octreotide and medium chain triglycerides, while surgical management is only considered if conservative measures fail and an anatomical cause is demonstrated.

1. Gastro Case Presentation
N Harper

2. Chylous ascites
• “True” Triglyceride > 1.24 mmol/L (200mg/dL)
• “Chyliform” lecthin-globulin complex, fatty degeneration
• “Pseudochylous” neutrophils
90% of cases malignancy or cirrhosis
1. Obstruction of lymphatic vessel flow
2. Exudate of chyle
3. Lymphatic vessel fistula

3. Other causes

4. Other causes

5. Malignancy (2/3 of all cases)
• Tumour markers –ve
• CT CAP (6/9/12)
– Small mesenteric lymph nodes
– Abnormal ill defined soft tissue right iliac fossa inf & post to caecal
pole
– Pancreatic pseudocyst
• Discussed radiology meeting (13/9/12)
– Mesenteric nodes small
– Soft tissue abnormality ill defined
– Not for radiologically guided biopsy
– Not for surgical biopsy

6. Pancreatitis (13 cases) & Postoperative
(disruption of lymphatics)
• MRCP (13/9/12)
– Pancreatic fluid collection contains a locule of air
– ? Being fed by upstream pancreatic duct
– “raises possibility that the collection and widespread
ascites being due to a major pancreatic duct disruption”
– Consider lymphoscintigraphy

7. Lymphoscintigraphy
• 99Tc sulphur colloid
suspended in saline
• Interdigital webspaces
• Massaged for 2 mins
• Images taken over 3-4
hours tracking spread

9. • Pancreatitis (13 cases) & Postoperative
– Lymphoscintigraphy
• Malignancy (2/3 of all cases)
• Nothing to biopsy

10. • Pancreatitis (13 cases) & Postoperative
– Lymphoscintigraphy
• Malignancy (2/3 of all cases)
• Nothing to biopsy
• Carcinoid (15 cases)
– Tumour markers, Chromogranin A&B

11. • Pancreatitis (13 cases) & Postoperative
– Lymphoscintigraphy
• Malignancy (2/3 of all cases)
• Nothing to biopsy
• Carcinoid (15 cases)
– Tumour markers, Chromogranin A&B
• TB
– Tuburculosis smear, Adenosine deaminase (ADA)

12. Conservative management
• Octreotide – somatostatin analogue
– Decreases splanchnic & portal blood flow & portal
pressure
• Long chain triglycerides (decrease)
– converted to monoglycerides and free fatty acids
– chylomicrons – interstitial lymph ducts
• Medium chain triglycerides (increase)
– absorbed directly into intestinal cells and
transported as FFAs and glycerol directly to the
liver via the portal vein

13. Surgical management
• Only if conservative measures fail and anatomical
cause demonstrated
• Of 156 patients with resolved chylous ascites, 51
treated surgically
• Peritoneovenous shunts – large complication rates
• Repeated paracentesis if not suitable for surgery