chronic chylous ascites , associated with malignant obstructions in the lymphatic channel , does not usually cause acute abdominal pain .
that is , chyle extravasation into the peritoneal cavity is rarely associated with the sudden development of peritonitis ( 1 ) .
we present a case of acute chylous peritonitis in a patient with advanced gastric carcinoma who presented with signs and symptoms of peritonitis caused by ovarian torsion .
the department of surgery was consulted for the finding of milky peritoneal fluid in a 41-yr - old female undergoing a complete abdominal hysterectomy with bilateral salphingo - oophorectomy ( tah - bso ) by a gynecologist at our institution .
the patient had been admitted to the yonsei university medical center , seoul , korea , for chemotherapy due to advanced gastric carcinoma . a previous computed tomography ( ct ) scan had shown bilateral metastatic ovarian tumors . during her stay ,
a physical examination revealed direct tenderness to palpation , rebound tenderness , and guarding ; she was also noted to have a palpable left supraclavicular node .
a chest radiography was normal ; an emergent abdominal pelvic ct scan showed increased bilateral ovarian tumors with minimal intraperitoneal fluid collection ( fig .
the initial blood laboratory results showed a total leukocyte count of 3,600/l with 58% neutrophils , hb 12.8 g / dl , platelet count 245,000/l , na 143 mm / l , k 3.9 mm / l , cl 103 mm / l , bun 13.6 mg / dl , creatinine 0.9 mg / dl , glucose 116 mg / dl , ast 20 iu / l , alt 14 iu / l , and total bilirubin 0.6 mg / dl . based on the physical examination and ct findings , peritonitis caused by ovarian torsion was strongly suspected , leading a gynecologist to perform an exploratory laparotomy on an emergency basis . in the operative field ,
however , a minimal to moderate amount of milky peritoneal fluid was observed in the pelvic cavity and along the right paracolic gutter .
after the tah - bso , the patient was evaluated at the department of surgery for chylous ascites . on intraperitoneal exploration ,
the stomach seemed to be tethered to the pancreas , but there was no evidence of peritoneal carcinomatosis .
diffuse lymphatic ectasia and milky fluid discharge were noted around the small bowel mesentery ( fig .
she was given a fat - free diet , and no evidence of reoccurrence of ascites was noted on clinical observation , such as the measurement of daily body weight and abdominal circumference .
chylous ascites is an uncommon finding , with an incidence of 1 in 20,000 hospital admissions ( 2 ) .
paracentesis is the most important diagnostic modality and reveals milky peritoneal fluid with a triglyceride concentration 2 to 8 times that of plasma ( 3 ) .
malignant lymphoma is the most common cause of chylous ascites and accounts for 50% of cancer - related cases ( 4 ) .
malignant invasion causes lymphatic channel fibrosis and disruption of the peritoneal cavity lymphatic system , enhancing extravasation distal to the obstruction .
other malignancies such as colon , pancreatic , stomach , ovarian cancers , and intestinal carcinoid , kaposi sarcoma , and lymphangiomyomatosis ( 5 ) can also cause chylous ascites .
other etiologies include infectious diseases , such as peritoneal tuberculosis and lymphatic filariasis , lymphatic system congenital anomalies , radiation side effects , abdominal surgery complications , and portal hypertension from liver cirrhosis ( 6 ) .
chronic chylous ascites usually does not present with acute abdominal pain , as mentioned previously . in the present case , the abrupt onset was accompanied by peritoneal signs that led to an emergency exploratory laparotomy due to a concern of ovarian torsion caused by large bilateral ovarian krukenburg 's tumors .
strictly speaking , the operative finding did not show any evidence of acute inflammatory changes in the patient 's peritoneal cavity ; however , clinical symptoms definitively suggested peritonitis , requiring immediate surgical intervention .
therefore , the diagnosis of acute chylous peritonitis may be more appropriate than that of chylous ascites , depending on the clinical setting .
although there was no gross lymphadenopathy or peritoneal cancer seeding , microscopic metastasis in the small lymphatic system was suspected as the etiology .
later it was revealed that the patient had left supraclavicular engorgement , which subsequently decreased after the laparotomy .
disruption of the abdominal cavity peripheral lymphatic system , caused by thoracic duct obstruction from a metastatic left clavicular lymph node , resulted in sudden extravasation and acute chylous peritonitis . in our hypothesis , if it had not been for the chylous ascites , the abrupt onset of chylothorax might have occurred , and would have presented with dyspnea as the initial symptom .
the optimal management of chylous ascites includes a protein - rich , low - fat diet , medium - chain triglycerides , sandostatin , and orlistat ( xenical ) ( 7 - 10 ) .
total parenteral nutrition can be used to decrease lymphatic flow and to promote lymphatic disruption closure .
although no drain catheters were placed , there was no evidence of further peritoneal fluid collection . in this case , the symptoms and signs of peritonitis were present ; however , there was no accompanying fever , leukocytosis , or intraperitoneal free air .
although spontaneous acute chylous peritonitis is rare , the disease should be considered in a patient with underlying malignant disease and signs of peritoneal irritation without associated leukocytosis , fever , and intraperitoneal free air . in these cases ,
laparoscopy prior to laparotomy would have confirmed chylous ascites and resulted in a less invasive surgical procedure .
 the extravasation of chyle into the peritoneal space usually does not accompany an abrupt onset of abdominal pain with symptoms and signs of peritonitis . 
 the rarity of this condition fails to reach preoperative diagnosis prior to laparotomy . here 
 , we introduce a case of chylous ascites that presented with acute abdominal pain mimicking peritonitis caused by ovarian torsion in a 41-yr - old female patient with advanced gastric carcinoma . an emergency exploratory laparotomy was performed but revealed no evidence of ovarian torsion . 
 only chylous ascites was discovered in the operative field . 
 she underwent a complete abdominal hysterectomy and salphingo - oophorectomy . only saline irrigation and suction - up 
 were performed for the chylous ascites . 
 the postoperative course was uneventful . 
 her bowel movement was restored within 1 week . 
 she was allowed only a fat - free diet , and no evidence of re - occurrence of ascites was noted on clinical observation . 
 she now remains under consideration for additional chemotherapy . 
INTRODUCTION
CASE REPORT
DISCUSSION