2000 Associates' Presentations
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It was not at all clear: An Unusual Cause of New Onset Ascites
Jeannina Smith, University of Wisconsin Medical School, Madison, WI
HPI: The patient is a 72-year-old woman referred for rapidly progressive abdominal distention and lower extremity swelling over the previous two weeks. An ultrasound of the abdomen showed a large amount of ascites and a normal liver.
Pertinent recent PMH: The patient had been in her usual state of health until three months prior when she experienced the sudden onset of severe low back pain. A CT scan of the abdomen revealed a 12cm leaking AAA with a large retroperitoneal hemotoma. She subsequently underwent an emergent AAA repair. Her post-operative course was complicated by pulmonary embolism, and bilateral lower extremity DVTs. She was started on an unfractionated heparin drip. A left upper extremity PICC line was placed for TPN administration and she also developed a catheter associated subclavian DVT. She was noted to have progressive thrombocytopenia. At that point, heparin antibodies were found to be present. She was switched from heparin to hirudin and coumadin. She was discharged after her INR was in therapeutic range. TPN and hirudin were stopped on her discharge. One month after discharge she complained of increased lower extremity swelling. Her INR was found to be subtherapeutic. Ultrasound showed persistent lower extremity clot, so she was started on enoxaparin as a bridge for two days until her INR was again therapeutic.
Hospital course: Given her history, it was initially feared that she had ascites secondary to Budd-Chiari syndrome or hepatic vein thrombosis secondary to the hypercoagulable state induced by her heparin induced thrombocytopenia syndrome. Paracentesis was performed. This revealed thin, milky white fluid, which was rich in triglyerides. Diagnosis of chylous ascites was made. A CT of the abdomen failed to reveal any compression of the thoracic duct, mass, or inflammation. Patient was started on TPN and a medium chain triglyceride diet. On follow up her ascites had resolved and she was feeling well.
Discussion: Chylous ascites. Chylous ascites is an unusual phenomenon characterized by leakage and sequestration of large volumes of chyle in the peritoneal cavity. It can have multiple serious consequences in the following areas: nutritional, immunologic, and mechanical. In most cases, chylous ascites is associated with intra-abdominal malignancy or inflammation. Elemental diet supplementation or TPN may be used to minimize lymphatic drainage and promote healing of the lymphatics. Additionally, since medium chain triglycerides are absorbed directly into the portal venous system, a medium chain triglyceride diet may be used. Conservative approach is favorable: however, if that is not successful, operative management to ligate the offending lymphatics can be undertaken. However, operative management is associated with significant morbidity.
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