Cylous Ascites in Gynaecology Malignancy

Deri Edianto

, Isnayu Jurimal

and Muhammad Rizki Yaznil

Department of Obstetrics and Gynecology, Universitas Sumatera Utara, Medan, Indonesia

Keywords: Chylous Ascites, Lymph Nodes, Malignancy, Paracentesis.

Abstract: Chylous ascites is ascites caused by leakage of lymphatic fluid which contain lipid to peritoneal cavity and a

rare malignancy complication. Chylous ascites was reported in 1 from 2000 cases in 20 years. We report a

59 years old housewife, para 3, who was admitted to emergency unit Adam Malik General Hospital with

abdominal enlargement. She has been experiencing this in the last 2 months ago. The signs and symptoms

were nausea, vomiting, loss of appetite. She was diagnosed with carcinoma of the cervix stage II B on

October 2016 and received chemoradiation (external beam radiotherapy 28x, chemotherapy 6x,

brachytherapy 6x) in other hospital. The general findings were within normal limit. BMI was 15.82 kg/m

(underweight). On physical examination, head, neck, and chest within normal findings. Abdominal findings

were enlargement, distension, shifting dullness, no mass was palpable. The cervix looks fibrotic and no

residual mass visible. Laboratory findings are thrombocytosis (629.000/mm

), hypoalbuminemia (2,7 g/dL),

blood urea was within normal value, creatinine was 1,58 mg/dL. Electrolyte values were within normal

except hyponatremia (132 mEq/L). Chest X-ray examination was atelectasis at right middle lung. CT scan

finding suggested metastatic process in the liver. The patient was diagnosed with cervical cancer II B post

chemoradiotherapy metastasize to the liver, massive ascites and hypoalbuminemia. Abdominal Paracentesis

findings were 4000 ml of white milky fluid and the levels of triglycerides in the ascitic content were 1057

mg/dl. As a conclusion, chylous ascites is very rare with malignancy and cirrhosis are the main causes.

Diagnosis of chylous ascites is paracentesis with increased triglyceride levels and the management mainly

conservative.

1 INTRODUCTION

Ascites is a collection of fluid in peritoneum space.

This condition happens when there is excessive fluid

production and inadequate absorption. Ascites is one

of many malignancy complications. Four in five

patients with malignancy ascites were caused by

ovarian cancer, gastrointestinal, breast, pulmonary,

uterine, and cervical cancer. Patients with malignant

ascites have poor prognosis with life expectancy

only 1-4 months and five years survival rate is

48,7% (Damodar and Rao, 2011)

Chylous ascites is caused by leakage of

lymphatic fluid that contains lipid to peritoneal

space. Chylous ascites can be caused by surgical

trauma to lymphatic vessels, tuberculosis, cirrhosis,

lymphoma, radiotherapy, and direct lymphatic

metastases. Reported incidence of chylous ascites is

1 from 20.000 cases in 20 years. The incidence

predicted to be increasing because of increasing life

expectancy in cancer patients and increasing

aggressive cardiothoracic and abdominal

intervention (surgery). Al-Busafi found that chylous

ascites incident were 1 in 11.589 cases in 2013.(Al-

Busafi et al., 2014) So it is still a very rare

complication of malignancy or its treatments.

Treatment of chylous ascites is still

controversial. It can be standard conservative

treatment or surgery for unresponsive

patients.(Solmaz et al., 2015)

2 CASE REPORT

Mrs.N, 59 years old, P3A1, housewife, who was

admitted to emergency unit Adam Malik general

hospital on June 12

, 2017 with an abdominal

enlargement. She has been experiencing this

condition in the last 2 months. The signs and

symptoms were nausea, vomiting, history loss of

Edianto, D., Jurimal, I. and Yaznil, M.

Cylous Ascites in Gynaecology Malignancy.

DOI: 10.5220/0010070504330435

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

433-435

ISBN: 978-989-758-449-7

433

appetite, history of weight loss. There were no

abdominal pain, vaginal bleeding and discharge. She

was diagnosed with carcinoma of the cervix stage II

B on October 2016 and received chemoradiation

(external beam radiotherapy 28x, chemotherapy 6x,

brachytherapy 6x) in other hospital, last procedure in

February 2017. Menarche at the age of 14 years old

with regular 28 - 30 days cycle, lasting for 5 – 7

days. Menopause at 54 years old.

Vital sign was normal. BMI was 15.82 kg/m

(underweight). On physical examination, head, neck,

and chest were normal. Abdominal were

enlargement, distension, shifting dullness (+), no

mass was palpable. The bowel sound was present

and revealed normal. The inspection showed fibrotic

cervix. In vaginal examination there were palpated

fibrotic cervix, normal uterine size, no locoregional

residual mass.

Full blood count was normal except

thrombocytosis (629 000/mm

). Liver function test

was normal. The patient was hypoalbuminemia with

serum albumin level 2,7 g/dL. Blood urea was

normal, creatinine was 1,58 mg/dL. Electrolyte

values were normal except slight hyponatremia (132

mEq/L). Chest X-ray examination was plate-like

atelectasis at right middle lung. CT scan findings

were multiple metastatic nodule in the liver, bilateral

pleural effusion and ascites, bilateral kidney atrophy,

especially the left kidney.

Paracentesis findings were 4000 ml of white

solid-fluid from ascitic patient (Figure 1). The

patient was treated with intraperitoneal

chemotherapy with cisplatin 100 mg in normal

saline 2 litres. Cytologic result was metastatic

carcinoma. Analysis of peritoneal fluid were in

Table 1.

Figure 1: Chylous ascites

Table 1: Analysis of ascites fluid

3 DISCUSSION

Chylous ascites is a collection of lymphatic fluid

from peritoneal space with high triglycerides content

more than 110 mg/dL. Lymphatic system consists of

lymphatic fluid, lymphatic vessels, and bone

marrow. Thoracic duct is a point where there is a

transition and mixture of many chylomicrons and

less lymphatic fluid. If lymphatic fluid is above

cisterna chylous, it is called chylous and milky

because it contains high triglyceride. If the fluid is

located below the point of transition, it is known as

lymphatic where the triglyceride level is minimal

and it is clear or reddish.(Micha et al., 2012; Al-

Busafi et al., 2014)

Three basic mechanisms of chylous ascites are

primary fibrosis of lymphatic nodes caused by

obstruction of lymphatic drainage from gut to

chylous cisterna from sub serous lymphatic from

malignancy, lymphatic fluid exudation to peritoneal

space and direct lymphatic fluid leakage (lymph

peritoneal fistulae) caused by thoracic duct

obstruction.(Cárdenas and Chopra, 2002)

Chylous ascites can be caused by traumatic and

atraumatic. Atraumatic condition such as

malignancy, cirrhosis, mycobacterium infection, and

others.(Al-Busafi et al., 2014) Our patient was

diagnosed with cervical cancer stage II B. Ascites is

one of the complication of malignant process

(incidence up to 2%). The traumatic condition is

direct lymphatic trauma, one of which is due to

Colou

Milky white

Total

protein

1.34 g/dl Transudate

(< 3gr/dl)

Exudate (>

r/dl)

LDH 112 U/L Transudate

(< 200

U/L)

Exudate (>

200 U/L)

Glucose 147 m

/dl 55-140

H8 7-8

WBC 0.343 10

/uL

RBC 0.002 10

/uL

MN cell 91.3 %

PMN cell 8.7 %

Total

cholesterol

55 mg/dl < 200

Tri

ceride 1057 m

/dl 40-200

Albumin 0.5 g/dl 3.5-5.0

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

434

radiotherapy. Hurst and Edward reported cases of

chylous ascites after radiotherapy. During the

explorative laparotomy, there is a damage of small

intestine and chylous leak.(Lentz et al., 1990) Our

patient was received chemoradiotherapy treatment

(external beam radiotherapy 28x, cisplatin

chemotherapy 6x and brachytherapy 6x).

Several clinical findings are progressive and

abdominal distention (81% with pain) and

nonspecific pain (14%). Other symptoms are

dyspnoea, weight loss, anorexia, malaise,

steatorrhea, malnutrition, lymphatic enlargement,

and night sweat. Physical examination findings are

ascites, pleural effusion, lower extremity edema,

lymphadenopathy, cachexia, weight loss, and

hernia.(Cárdenas and Chopra, 2002; Steinemann et

al., 2011; Al-Busafi et al., 2014)

In laboratory findings, abdominal paracentesis is

the main diagnostic tools and very important for

evaluation and treatment.(Baiocchi et al., 2010; Al-

Busafi et al., 2014)

Chylous ascites is a milky-

appearing fluid with high levels of triglycerides that

are usually >110 mg/dl or > 1,2 mmol/l.(Steinemann

et al., 2011) Additional examinations are CT scan,

lymphoscintigraphy to detect abnormal lymphatic

drainage, laparoscopy and laparotomy. Abdominal

paracentesis from our patient were 4000 ml of milky

and cloudy fluid and levels of triglycerides in ascitic

fluid were 1057 mg/dl.

Conservative management of chylous ascites are

low-fat diet, decreasing intestine lymphatic drainage,

triglyceride lymphatic transport, Total Parenteral

Nutrition (TPN), somatostatin and abdominal

paracentesis to reduce the symptoms. Other therapy

for unresponsive cases are Trans-jugular Intrahepatic

Portosystemic Shunt (TIPS), angiography and

peritoneovenous shunt (Manolitsas et al., 2002; Al-

Busafi et al., 2014)

4 CONCLUSIONS

Chylous ascites is a kind of ascites that happened

very rarely. Malignancy and cirrhosis are the main

etiology for adult patient, while for children the

etiology usually congenital abnormalities and

trauma. The diagnostic of chylous ascites made with

analysis of triglycerides content of ascitic fluid from

paracentesis. The treatment of underlying disease is

the first important step to treat the patients.

Treatments such as low-fat diets, triglycerides

intake, paracentesis, TPN and somatostatin could be

considered. For refractory cases, we could use

Trans-jugular Intrahepatic Portosystemic Shunt

(TIPS), exploratory surgery and peritoneovenous

shunt.

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