Gastro Case Presentation

N Harper

Chylous ascites• “True” Triglyceride > 1.24 mmol/L (200mg/dL)

• “Chyliform” lecthin-globulin complex, fatty degeneration

• “Pseudochylous” neutrophils

90% of cases malignancy or cirrhosis

1. Obstruction of lymphatic vessel flow

2. Exudate of chyle

3. Lymphatic vessel fistula

Other causes

Other causes

Malignancy (2/3 of all cases)

• Tumour markers –ve

• CT CAP (6/9/12)– Small mesenteric lymph nodes

– Abnormal ill defined soft tissue right iliac fossa inf & post to caecal pole

– Pancreatic pseudocyst

• Discussed radiology meeting (13/9/12)– Mesenteric nodes small

– Soft tissue abnormality ill defined

– Not for radiologically guided biopsy

– Not for surgical biopsy

Pancreatitis (13 cases) & Postoperative(disruption of lymphatics)

• MRCP (13/9/12)

– Pancreatic fluid collection contains a locule of air

– ? Being fed by upstream pancreatic duct

– “raises possibility that the collection and widespread ascites being due to a major pancreatic duct disruption”

– Consider lymphoscintigraphy

Lymphoscintigraphy

• 99Tc sulphur colloid suspended in saline

• Interdigital webspaces

• Massaged for 2 mins

• Images taken over 3-4 hours tracking spread

• Pancreatitis (13 cases) & Postoperative– Lymphoscintigraphy

• Malignancy (2/3 of all cases)• Nothing to biopsy

• Pancreatitis (13 cases) & Postoperative– Lymphoscintigraphy

• Malignancy (2/3 of all cases)• Nothing to biopsy

• Carcinoid (15 cases)– Tumour markers, Chromogranin A&B

• Pancreatitis (13 cases) & Postoperative– Lymphoscintigraphy

• Malignancy (2/3 of all cases)• Nothing to biopsy

• Carcinoid (15 cases)– Tumour markers, Chromogranin A&B

• TB– Tuburculosis smear, Adenosine deaminase (ADA)

Conservative management• Octreotide – somatostatin analogue– Decreases splanchnic & portal blood flow & portal

pressure

• Long chain triglycerides (decrease)– converted to monoglycerides and free fatty acids –

chylomicrons – interstitial lymph ducts

• Medium chain triglycerides (increase)– absorbed directly into intestinal cells and transported as

FFAs and glycerol directly to the liver via the portal vein

Surgical management

• Only if conservative measures fail and anatomical cause demonstrated

• Of 156 patients with resolved chylous ascites, 51 treated surgically

• Peritoneovenous shunts – large complication rates

• Repeated paracentesis if not suitable for surgery