S5454 A Rare Presentation of Chylous Ascites Secondary to Thrombosis

Introduction: Chylous ascites is the accumulation of milky white peritoneal fluid rich in triglycerides due to the leakage of thoracic or intestinal lymph into the abdominal cavity. The leading etiology in adults is secondary to abdominal malignancy, cirrhosis, infections and iatrogenic trauma. It is a rare presentation with a reported incidence of 1 in 20,000 admissions as estimated by a study in 1992. Case Description/Methods: This case report describes a 40-year-old man, a daily wage laborer, who presented with a gradually progressive abdominal distension, scrotal swelling and new onset shortness of breath. There was no fever, hematemesis, jaundice, pedal edema or urinary symptoms. The patient is a diabetic, chronic alcoholic and non smoker. Clinical examination revealed a distended abdomen with mild splenomegaly, shifting dullness and clear bowel sounds. A transilluminant scrotal swelling could be appreciated with no hernia. Routine blood investigations were normal. A diagnostic paracentesis revealed milky white fluid with an elevated triglyceride count of 700 mg/dL, a low Serum Ascites Albumin Gradient (SAAG) score of 0.5 and plenty of lymphocytes on cytology. There were no malignant cells or pathogenic organisms on staining. Abdominal ultrasound showed splenomegaly with normal liver morphology. Doppler Ultrasound of Spleno-Portal Axis revealed portal vein thrombosis and dilated portal vein with cavernomas. Further, a computed tomography (CT) Chest and CT Abdomen showed internal jugular vein thrombosis with minor extension into the subclavian vein, later confirmed by a CT Venogram. Thrombophilia screen for hypercoagulable disorders was normal. An upper GI endoscopy revealed esophageal varices. The patient was treated conservatively with propranolol, diuretics, therapeutic paracentesis and a high protein low fat diet. Significant improvement was seen 8 days after commencing treatment. Cardiothoracic surgeons opined that a stent placement would not improve the outcome. In view of long standing thrombosis the patient was started on warfarin with a target international normalized ratio of 2-3 and discharged. Discussion: Venous thrombosis at 2 different sites i.e. portal vein and internal jugular vein, draws attention to a rare cause of chylous ascites in the absence of cirrhosis or malignancy. It is likely idiopathic as no pre-existing hypercoagulable condition was found. In many such cases, conservative medical management as mentioned above remains the most effective option with a favorable prognosis.