CHYLOUS ASCITES AFTER SEVERE ACUTE PANCREATITIS: A CASE REPORT AND REVIEW OF THE LITERATURE

M Alghamdi, A Bedi, B Reddy*, R Tanton, K Peltekian

Dalhousie University, Halifax, Nova Scotia, and *Memorial University, St. John's, Newfoundland

Malignancy, surgical trauma and cirrhosis are causes of chylous ascites in more than 80% of cases. We report a case of a patient with chylous ascites following severe acute pancreatitis, with literature review focusing on prevalence and treatment of chylous ascites.
A literature search using PubMed from 1965 to present revealed pancreatitis to be a rare cause of chylous ascites, with only six cases reported. Multiple treatments have been attempted for chylous ascites, including fistula repair, octreotide and total parenteral nutrition (TPN) with variable results.
A fifty year old male with insulin dependent diabetes presented with abdominal pain, vomiting, and elevated amylase and lipase. The patient was diagnosed with severe acute alcoholic pancreatitis, which resolved after one week of conservative treatment. Four weeks later patient started developing abdominal distension and increased girth. Diagnostic paracentesis confirmed ascites to be chylous. Investigations for chronic liver disease, liver cirrhosis, malignancy, and infection were all negative; there was no surgical history. Both CT and MRI revealed calcification of pancreas, consistent with chronic pancreatitis. Lymphangiogram was suboptimal but did reveal any obvious fistulae or obstruction. On laparoscopy mesenteric lymph nodes were biopsied showing fat necrosis. There was no evidence of malignancy or infection. The patient was treated aggressively with sodium restricted low fat diet and supplementation of medium chain triglycerides plus subcutaneous injections of octreotide but then advanced to TPN. Over a period of 4 to 6 weeks, the ascites disappeared. After 2 months TPN and octreotide were discontinued. After 3 months, patient had fully recovered.
Fat necrosis has been associated with pancreatitis secondary to digestion by pancreatic lipases and colipase, but there is no previous report of fat necrosis in association with chylous ascites due to pancreatitis.