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Indian Journal of Surgery, Vol. 64, No. 6, Nov - Dec. 2002, pp. 525-526 Case Report Acute Chylous Peritonitis Parimal Bhattacharya Sethi Diagnostic & Medicare Pvt. Ltd., 69, Diamond Harbour Road, Calcutta
- 700 038. Paper received: May 2001 Code Number: is02011 Abstract Acute abdomen with signs and symptoms of peritonitis due to sudden extravasation of chyle into the peritoneal cavity is a rare condition. The chronic form of chylous ascites, also uncommon, does not produce acute symptoms and many of them are secondary to other intra-abdominal pathology. The acute form of chylous ascites is without any detectable cause in majority of the cases. Patients present with signs and symptoms of acute abdomen indistinguishable from peritonitis due to perforation of hollow viscus. Complete recovery is the usual outcome. We report a recently treated case because of its rarity. Key words: Acute chylous peritonitis, peritoneal irritation INTRODUCTION Acute chylous ascites is a rare cause of acute abdomen. One such patient who had a complete recovery is presented here. CASE REPORT A fifty-nine year old man was admitted as an emergency with history of sudden onset of upper abdominal pain getting worse over the previous 24 hours. The pain started in the epigastrium but gradually spread all over the abdomen. There was no nausea or vomiting. He passed one loose motion an hour after the onset of pain. There was no significant past medical history apart from dyspepsia. On examination he appeared in pain and was well hydrated, apyrexial, normotensive and had a pulse rate of 100/minute. The abdomen was slightly distended with generalized tenderness and guarding, most marked in the right lower abdomen. Bowel sounds were present A straight X-ray of abdomen showed loops of gas filled small intestine but no fluid level or free gas under the diaphragm. Erect chest x-ray was normal. White cell count was raised to 12,000 / cu mm with a normal differential count. Other biochemical tests were normal. Within two hours his symptoms became worse and the abdominal signs became more marked. A diagnosis of peritonitis due to viscus perforation was made, possibly an appendicular perforation. The abdomen was opened through a Mc-Burney's incision. On opening the peritoneum milky fluid came out. Appendix was normal. A standard appendicectomy was done and the incision closed. Laparotomy through a right paramedian incision was next carried out which revealed about five hundred ml. of odourless milky white fluid. After a thorough search no perforation of any viscus or any other pathology could be identified. The milky fluid was seeping out from the posterior peritoneum. The same fluid could also be seen within the layers of small bowel mesentery as far as the bowel wall. A diagnosis of acute chylous peritonitis was made. Abdominal cavity was washed with normal saline and closed with a tube drain. Drainage through the tube stopped within seventy two hours and the total drainage was about four hundred ml. Biochemical analysis of the fluid by electrophoresis confirmed it to be chyle. Culture of the fluid showed no growth. Patient made an uneventful recovery. DISCUSSION Aetiology of acute chylous peritonitis includes1 a) rupture of congenital chylous mesenteric cyst, b) trauma to the cysterna chyli or lymphatic trunks, c) obstruction to the bowel or to the thoracic duct, common causes being infiltration by malignant tumours like Hodgkin's disease, lymphosarcoma or tuberculous lymphadenitis and d) idiopathic without any detectable cause. The case reported here falls into the idiopathic group. In the world literature only about sixty cases of acute chylous peritonitis have been reported. The first case was reported in 1910 by Renner.2 Suggestion has been made that overloading of the lymphatic channels with chyle after a heavy fatty meal cause extravasation of chyle intraperitoneally and retroperitonealy.3 This patient however had taken a small non-fatty meal before the onset of his illness. Peritoneal irritation with acute signs and symptoms is absent in chronic chylous ascites. Chyle is a relativity non-irritant to serosal surfaces. Why peritoneal irritation should develop in some patients is not known. Bird4 postulated that sudden stretching of retroperitoneal and mesenteric surfaces by the dissecting chyle causes the irritation. It is possible that the condition has a self-limiting course as all the reported patients had a smooth and full recovery with spontaneous cessation of the chyle leak. In the reported series there was no difference in the postoperative recovery of patients irrespective of whether abdominal cavity was drained or not. Use of a drain is probably not necessary.5 Diagnosis in all the cases was made only after laparotomy.6 In the present day an age, of increasing utilisation of diagnostic laparoscopy in patients with acute abdomen, this modality may well have a role to play in management of patients with chylous peritonitis. REFERENCES
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