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Chylous Ascites, also known as "chylous peritoneum" can be defined as a milky-looking fluid rich in triglycerides (concentration above 200 mg/dL) within the peritoneal cavity. It is a dangerous and rare condition, challenging to manage and with a high rate of morbidity. This clinical condition typically occurs when there is a disruption of the lymphatic system, generally due to an obstruction of lymph nodes, tumors, congenital anomalies, abdominal trauma (or obstruction of the thoracic duct due to trauma), exudation from dilated vessels, fistula or post-surgical procedures, causing changes in lymphatic vessel pressure. Thus, when lymph flow is interrupted, there is an increase in pressure within the lymphatics, leading to distortion and dilation of vessels and insufficient valvular structures. Consequently, chylous reflux occurs into various areas, including the peritoneum. The clinical presentation comes as progressive and painless abdominal distension or the observation of withdrawn fluid with a milky appearance.
This is a case report.
We present a case study of a 64-year-old white male patient from Salvador, Brazil, with a history of hypertension and 18 years of Olmesartan use, undergoing peritoneal dialysis since October 2018. The patient was admitted with a complaint of a change in the color of the dialysate 48 hours prior (image 01). He denied fever, altered bowel habits or abdominal pain. The admission for abdominal pain investigation led to the initiation of Cefazolin and Ceftazidime. Routine cytology of peritoneal fluid revealed 14 cells and gram staining and cultures for aerobic bacteria, tuberculosis, and fungi were negative, ruling out peritonitis. Triglyceride analysis of peritoneal fluid confirmed chylous ascites with a level of 205mg/dL. Empirical antibiotic therapy was administered for seven days, and within 72 hours, the dialysate had returned to its usual clear and transparent color. This case highlights the importance of monitoring dialysate color as a diagnostic tool for complications in peritoneal dialysis patients. In this context, the patient reported a high-fat diet intake and intense abdominal exercises with compression and impact, suggesting a potential link to the rupture of lymphatics and the extravasation of lipid metabolism products into the abdominal cavity.
Chylous ascites is a rare condition that emerges as a possible etiology in the differential diagnosis of causes for cloudy/milky dialysate. In this context, the measurement of triglycerides (TG) in peritoneal fluid should be included in the initial laboratory investigation in these cases. The patient underwent abdominal tomography, which did not reveal abdominal lymphadenopathy (lymphoma being a potential cause of chylous ascites). After 7 days of empirical antimicrobial treatment, the patient was discharged on peritoneal dialysis with his usual prescription, displaying normal dialysate color, and without the need for additional measures. The patient was advised to avoid engaging in high-impact physical exercises in the abdominal region. The initial management of chylous ascites involves a conservative approach with a protein-rich and medium-chain lipid-restrictive diet, as it reduces lymph production and flow, along with parenteral nutrition. Another alternative is the use of somatostatin or octreotide for pharmacological treatment. Surgical intervention is an option for cases where these treatments prove ineffective, although there is no consensus in the literature regarding the optimal timing and approach to avoid unfavorable outcomes. Thus, it is imperative to underscore the importance of giving due consideration to this pathology.