EP110 - Chyloperitoneum in Follicular lymphoma – presenting as an inguinal hernia

Abstract Introduction Follicular lymphoma is one of the subtypes of slow growing Non-Hodgkin Lymphoma. Rarely, follicular lymphoma can present with chyloperitoneum or chylous ascites which is characterized by a milky-white coloured fluid with raised triglyceride levels. Case Report We present a case of a 60-year-old diabetic male, complaining of a right sided inguinal swelling for 1 year. Examination revealed a reducible right inguinal swelling with a positive cough impulse. The laboratory workup was unremarkable. Ultrasound scan of anterior abdominal wall showed a defect of 2.1 cm in right inguinal region with protrusion of abdominal contents and a positive cough impulse. A diagnosis of right sided reducible direct inguinal hernia was made. Patient was scheduled for Lichtenstein repair. Per-operatively, the hernial sac contained healthy omentum with milky-white ascitic fluid. Omentum was reduced and suture repair was performed. A drain was placed intra-peritoneally. The postoperative course of the patient was uneventful. Ascitic fluid analysis showed high triglyceride levels and no evidence of malignant cells, suggesting chylous ascites. Contrast enhanced CT scan of abdomen and pelvis revealed a large homogenous minimally enhancing soft tissue density retroperitoneal mass in peri aortic and paravertebral location with abdominal lymphadenopathy suggesting retroperitoneal lymphoma. Excisional biopsy of an enlarged inguinal lymph node confirmed follicular lymphoma with positive BCL2 and CD10 markers. Conclusion Follicular lymphoma presents in a variety of ways including chylous ascites in an inguinal hernia and a high index of suspicion is required to diagnose it.