Acute Chylous Peritonitis Simulating Acute Appendicitis: A Case Report and Review of the Literature

Abstract

Chylous effusions into pleural and peritoneal cavities are unusual, and are often a manifestation of an underlying disease process. A sudden outpouring of chyle into the peritoneal cavity may, on rare occasions, produce acute chylous peritonitis. Such patients usually present with features of acute abdomen, however, the diagnosis is rarely suspected preoperatively. Very few cases of acute chylous peritonitis have been described in the literature, and to the best of our knowledge, this is first of its kind in Saudi Arabia. Due to its rarity and presentation as compared to a common surgical emergency such as acute appendicitis, the clinical features and management of acute chylous peritonitis are discussed. Case ReportA 25-year-old Nigerian male was referred to the emergency room of King Fahad Hospital, in Medina, Saudi Arabia, because of generalized abdominal pain, vomiting and anorexia of three days' duration. The pain had started as a dull ache just above the umbilical region, had gradually increased in severity and become generalized. A day prior to his admission, the pain had localized to the right lower quadrant of the abdomen. The pain was continuous, severe and aggravated by any movement. The patient did not give any history of previous trauma or similar pain. He had been unable to take anything orally for over 24 hours prior to admission. There was nothing relevant in his past medical history, except that five years previously, he had been hospitalized for respiratory infection for five days. Details of this were not available. For the previous six years, the patient had been smoking about thirty cigarettes per day. He had not consumed alcohol for the past two years. There was no history of diabetes, hypertension, hyperlipidemia or recurrent abdominal pains in his family.On examination, the patient was mildly dehydrated. His temperature was 37.5°C, pulse rate was 115/min, and blood pressure was 110/85 mm Hg. Systemic examination was unremarkable. The abdomen was not moving adequately with respiration, and there was pain on coughing, especially in the right lower quadrant. The flanks were not full. There was guarding and tenderness all over the abdomen, especially in the right iliac fossa. Bowel sounds were audible. Total leukocyte count was 20,000/μL, Hb 16.8 g%, urea 4.3 mmol/L, creatinine 87.9 mmol/L, glucose 4.6 mmol/L, ALT 22 IUL, AST 28 IUL, amylase 104 IUL, cholesterol 3.5 mmol/L and triglycerides 0.34 mmol/L. Chest x-ray was normal. Abdominal x-ray showed nonspecific gas-filled loops of large intestine. The patient was suspected to have acute appendicitis with possible perforation.The abdomen was opened by right grid-iron incision, revealing unusually pale and white subcutaneous fat. The epimysium over the fibrous sheath aponeurosis of external oblique showed multiple strands with an interwoven network of whitish streaks. Between the strands was a whitish thickening of 1-2 mm. When the peritoneum was opened, milky white, odorless, non-clotting fluid gushed out. About one liter of this fluid was dra...

A rare cause of acute abdomen: Chylous ascites

“…With lymphoscintigraphy, lymph flow rate and peritoneal fistulas can be evaluated (8). In our study, however, lymphoscintigraphy was not useful to detect the leak, probably because of low output chyle leak.…”

“…In medical literature, we found five patients with spontaneous chylous ascites that clinically mimic acute appendicitis. As in our case, none of these patients had a significant reason for the etiology of ascites (7,8).…”

Idiopathic chylous ascites simulating acute appendicitis: A case report and literature review

“…This provides definitive diagnosis and correction of cause both laparoscopically or through microsurgical techniques [18]. When a specific cause is not identified at the time of surgery, retroperitoneal dissection is not advisable as spontaneous closure of leak and complete recovery is the rule, as occurred in our case [13].…”

“…Its chief characteristics include milky appearance, alkaline chemical properties, specific gravity greater than 1.012, stain positive for fat (Sudan III) and ether test, bacteriostatic in nature, sterile in culture and resisting putrefaction [12]. It is odorless, and only occasionally smells like digested food [13]. Its chemical composition is quite specific.…”

Acute Appendicitis Together with Chylous Ascites: Is It a Coincidence?

“…In our case, most of the fluid had been collected in the lower right quadrant. In the English language medical literature, there are five studies in which acute appendicitis had been clinically mimicked, but in all of them the appendix was normal and no explanation could be found for the clinical manifestation of chylous ascites [1, 3, 13, 15, 16]. In the light of this, to the best of our knowledge, we are presenting the first case of actual appendicitis together with chylous ascites.…”