Introduction: Chylous ascites is a rare milky appearing ascites that occurs due to the presence of triglyceride rich lymph in the peritoneum. This lymph extravasation forms due to dysfunction of the lymphatic system from trauma or obstruction. The most common causes in developed countries are cirrhosis and malignancy.
Description: This is a case of a 53-year-old male with a medical history of cirrhosis secondary to hepatitis C and recurrent admissions for tense ascites who was found altered and hypoxic. CT imaging revealed moderate pleural effusions, extensive mediastinal, hilar, axillary, retroperitoneal, and mesenteric adenopathy, massive ascites, and splenomegaly. He was admitted to the intensive care unit for management of respiratory failure with bilateral pleural effusions requiring intubation and hepatic encephalopathy in the setting of decompensated cirrhosis. A diagnostic paracentesis was indicated due to the presentation of decompensated cirrhosis and shock. Paracentesis unexpectedly revealed 4500cc of milky appearing ascitic fluid prompting suspicion for chylous ascites. This was confirmed through ascitic fluid testing with a triglyceride level > 500. Confirmation of chylous ascites led to a further workup to identify the underlying cause. Chylous ascites was suspected in the setting of malignancy due to extensive lymphadenopathy on imaging, splenomegaly, and prior paracentesis suggestive of lymphoproliferative disorder. An excisional biopsy of an axillary lymph node revealed atypical CD5+ cells which was highly suspicious for lymphoma. Due to his critical illness and progressive multi-organ failure, his family elected to focus on comfort care and he unfortunately did not survive hospitalization.
Discussion: Paracentesis is the single most important diagnostic test for chylous ascites and this rare diagnosis is made from clinical appearance and analysis of the ascitic fluid. Finding of milky ascitic fluid should prompt triglyceride level testing and a triglyceride level > 200 is considered to be the cutoff value for diagnosis. Further testing to determine the underlying cause, especially malignancy, is indicated once chylous ascites is confirmed. This finding, as well as a biopsy with tumor cells, was consistent with lymphoma which was previously undiagnosed in this patient
