INTERSTING CASE OF ASCITES<br />                                                                                          ...
63yrs old male admitted with<br />   C/O  <br />         Abdominal distension - 1 month<br />         Bilateral leg swelli...
History of present illness:<br />Abdominal distension -1month duration,<br />                        -slowly progressive, ...
No H/O jaundice, hematemesis, melena<br />No H/O Loose stools<br />No H/O fever<br />H/O Loss of appetite +<br />H/O Loss ...
PAST HISTORY<br />H/O jaundice present - 6yrs back<br />                            -details not known<br />Not a known SH...
PERSONAL HISTORY<br />Mixed diet<br />Known chronic alcoholic<br />                     ->10yrs<br />                     ...
EXAMINATION<br />General examination<br />Conscious<br />Oriented<br />Afebrile<br />Dyspneic<br />Mild pedal edema <br />...
SYSTEMIC EXAMINATION<br />CVS  – S1, S2 Heard<br />              no murmurs<br />RS    – NVBS Heard<br />              no ...
IMPRESSION<br />Ethanol related DCLD with ascites<br />? Malignant transformation<br />
INVESTIGATIONS<br />CBC<br />Hb -9 gm / dl<br />TC   - 5400<br />DC  - P-60 L-30 E-10<br />ESR   - 10 / 22mm<br />MCV - 88...
RFT<br />Blood sugar - 81 mg/dl<br />Urea           - 30mg /dl<br />Creatinine   - 0.9mg /dl<br />
USG ABDOMEN<br />Liver – 9.5 cm , altered texture , nodular surface <br />             Free fluid +<br />GB – Apparent GB ...
ASCITIC FLUID ANALYSIS<br />Appearance – milky (chylous) <br />Total  WBCs – 3000 cells/cumm<br />Neutrophils – 6-8 / hpf<...
Amylase - 271 u/ l<br />Cytology– <br />plenty of lymphocytes along with reactive mesothelial cells on eosinophilic backgr...
SP 3<br />Hb   -8.3 gm /dl<br />TC - 6900cells/cumm<br />DC  - P-63 , L-26 , E -11<br />Platelets – 16000<br />PCV -34.8<b...
Blood sugar  81mg/dlUrea          26.16 mg/dlCreatinine -1.12 mg/dl<br />Total bilirubin -0.52 mg/dl<br />Direct   -  0.2m...
SEROLOGY<br />HIV Antibody - negative<br />HBSAg  - negative<br />Anti  HCV -  negative<br />URINE  complete analysis<br /...
Urine microscopy<br />leucocytes 5-6 cells/hpf<br />EP cells – 2-3/ hpf<br />
Chest physician opinion:<br />                        - RT pleural effusion<br />OGD SCOPY:<br />                         ...
Pleural fluid analysis:<br />Sugar – 93<br />Protein – 2.8<br />
With the above investigations what are the possibilities?<br />Comment<br />Causes of ChylousAscites:<br />
Points favouring TB <br />↑ ascitic fluid ADA<br />↑ proteins  exudate<br />Right pleural effusion<br />Para-aortic nodes...
CT abdomen<br />Multiple para-aortic nodes+. Ascites with right pleural effusion.<br />CT being inconclusive, what to do n...
The small cervical nodes started becoming more conspicuous  <br />FNAC     -CERVICAL LYMPH NODE <br />possibility of chron...
INGUINAL NODE BIOBSY<br />Diffuse effacement of lymphnode architecture by monotonous population of neoplastic cells [lymph...
Patient had trouble with crossmatching   possible  Auto Immune Hemolytic Anemia<br />
Hematology opinion<br />Suggested<br />LDH <br />Hematocrit<br />To do Direct Coomb’s Test  to r/o AIHA<br />
Plan to start chemotherapy after blood investigation<br />But before we could start chemotherapy pt deteriorated and died ...
Final diagnosis<br />Small cell lymphoma infiltrating the liver causing portal hypertension and chylous ascites with possi...
CHYLOUS ASCITES<br />Chylousascites is an uncommon clinical condition that occurs as a  result of disruption of the abdomi...
CAUSES<br />Abdominal surgery<br />Abdominal trauma<br />Malignant neoplasms  hepatoma, small cell lymphoma, retro periton...
classification<br />True chylous ascites: fluid with high triglyceride content (>200mg%)<br />Chyliform ascites: fluid wit...
Chylousascites diagnosed by<br />-The ascitic fluid triglyceride level is elevated  in all pts with chylous ascites.<br />...
TREATMENT<br />Chylous ascites is a manifestation rather then a disease  depends on the treatment of the underlying diseas...
Non-hodgkin's Lymphoma of the Liver<br />Lymphomatous infiltration of the liver is more common in non-Hodgkin's lymphoma (...
Liver biochemical test results may be abnormal (primarily an increase in serum alkaline phosphatase), and hepatomegaly may...
Jaundice is rare in patients with NHL and in the past was considered a terminal occurrence. <br />Jaundice secondary to ex...
Treatment <br />Hepatic resection/Orthotopic liver transplant for primary hepatic NHL.<br />Chemotherapy for CLL/SLL with ...
		Thank you<br />
A Case of Chylous Ascites
A Case of Chylous Ascites
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A Case of Chylous Ascites

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A Case of Chylous Ascites

  1. 1. INTERSTING CASE OF ASCITES<br /> PROF. DR.P.VIJAYARAGHAVAN’S UNIT <br /> DR.C.R.RAJKUMAR <br />
  2. 2. 63yrs old male admitted with<br /> C/O <br /> Abdominal distension - 1 month<br /> Bilateral leg swelling -15 days <br />
  3. 3. History of present illness:<br />Abdominal distension -1month duration,<br /> -slowly progressive, uniform <br />Bilateral legs swelling – 15 days duration,<br /> -insidious, progressive<br />Shortness of breath – 15 days<br />Abdominal pain – past few days<br /> -diffuse, dull aching <br />Decreased urine output – past few days<br />
  4. 4. No H/O jaundice, hematemesis, melena<br />No H/O Loose stools<br />No H/O fever<br />H/O Loss of appetite +<br />H/O Loss of weight +<br />
  5. 5. PAST HISTORY<br />H/O jaundice present - 6yrs back<br /> -details not known<br />Not a known SHT / DM / PT<br />
  6. 6. PERSONAL HISTORY<br />Mixed diet<br />Known chronic alcoholic<br /> ->10yrs<br /> -180 – 270ml /105 gm / day<br />Chronic smoker<br />
  7. 7. EXAMINATION<br />General examination<br />Conscious<br />Oriented<br />Afebrile<br />Dyspneic<br />Mild pedal edema <br />Pallor+<br />An icteric<br />No clubbing<br />No cyanosis <br />Few lymph-nodes in left cervical region 0.5 to 1cm in size.<br />
  8. 8. SYSTEMIC EXAMINATION<br />CVS – S1, S2 Heard<br /> no murmurs<br />RS – NVBS Heard<br /> no added sounds<br />P/A –Soft<br /> distended<br /> firm to hard liver palpable<br /> irregular surface<br /> free fluid + fluid thrill+, <br /> few dilated veins  flow below upwards<br />CNS –NFND<br />
  9. 9. IMPRESSION<br />Ethanol related DCLD with ascites<br />? Malignant transformation<br />
  10. 10. INVESTIGATIONS<br />CBC<br />Hb -9 gm / dl<br />TC - 5400<br />DC - P-60 L-30 E-10<br />ESR - 10 / 22mm<br />MCV - 88 fl <br />MCH – 29pg<br />RBC – 5000 millions<br />PLATELETS – 80000<br />
  11. 11. RFT<br />Blood sugar - 81 mg/dl<br />Urea - 30mg /dl<br />Creatinine - 0.9mg /dl<br />
  12. 12. USG ABDOMEN<br />Liver – 9.5 cm , altered texture , nodular surface <br /> Free fluid +<br />GB – Apparent GB wall thickening+<br />Pancreas – 10 * 9 cm hetero echoic lesion in the <br />para aortic area displacing the pancreas<br />Spleen – 11.7 cm<br />Kidney – RT -10* 5.3 cm, left 9.9 * 4.5 cm increased echo , 1.8 * 2 cm cystic lesion in the upper pole of RT kidney multiple lesion in the LT kidney<br />IMPRESSION <br />Parenchymal liver disease with ascites. <br />Para aortic lymphadenopathy+ <br /> Bilateral renal cortical cyst.<br />
  13. 13. ASCITIC FLUID ANALYSIS<br />Appearance – milky (chylous) <br />Total WBCs – 3000 cells/cumm<br />Neutrophils – 6-8 / hpf<br />Sugar – 87 mg/dl<br />Total protein 2.9 gm /dl<br />Albumin 1.4 gm / dl<br />SAAG1.2<br />
  14. 14. Amylase - 271 u/ l<br />Cytology– <br />plenty of lymphocytes along with reactive mesothelial cells on eosinophilic backgrounds<br />Adenosine deaminase - 42.4 u/l<br />Ascitic fluid TGL: 210mg%<br />
  15. 15. SP 3<br />Hb -8.3 gm /dl<br />TC - 6900cells/cumm<br />DC - P-63 , L-26 , E -11<br />Platelets – 16000<br />PCV -34.8<br />MCV - 91.9<br />MCH - 29.6<br />MCHC- 32,5<br />ESR - 38 mm/hr<br />PT -14 sec<br />INR - 1<br />APTT - 26<br />
  16. 16. Blood sugar 81mg/dlUrea 26.16 mg/dlCreatinine -1.12 mg/dl<br />Total bilirubin -0.52 mg/dl<br />Direct - 0.2mg/dl<br />AST - 47u/l<br />ALT - 25 U<br />GGT - 30 U<br />SAP -249<br />Total protein -6.3 g/dl<br />Albumin -2.6 /dl<br />Globulin - 3.7 g/dl<br />Na+ -131.7 meq/l<br />k+ - 4.33 meq/l<br />Cl- 98.4meq/l<br />
  17. 17. SEROLOGY<br />HIV Antibody - negative<br />HBSAg - negative<br />Anti HCV - negative<br />URINE complete analysis<br />Colour - yellowish<br />Appearance - turbid <br />PH -6.0<br />Specific gravity -1.030<br />Albumin +<br />Sugar , blood , ketone - negative<br />Nitrite - negative<br />Bilirubin +<br />Urobilinogen - +<br />
  18. 18. Urine microscopy<br />leucocytes 5-6 cells/hpf<br />EP cells – 2-3/ hpf<br />
  19. 19. Chest physician opinion:<br /> - RT pleural effusion<br />OGD SCOPY:<br /> -Erosive gastritis<br /> - No esophageal varices<br />
  20. 20. Pleural fluid analysis:<br />Sugar – 93<br />Protein – 2.8<br />
  21. 21. With the above investigations what are the possibilities?<br />Comment<br />Causes of ChylousAscites:<br />
  22. 22. Points favouring TB <br />↑ ascitic fluid ADA<br />↑ proteins  exudate<br />Right pleural effusion<br />Para-aortic nodes<br />Points against – <br />High SAAG<br />How to proceed?<br />
  23. 23. CT abdomen<br />Multiple para-aortic nodes+. Ascites with right pleural effusion.<br />CT being inconclusive, what to do next??<br />
  24. 24. The small cervical nodes started becoming more conspicuous <br />FNAC -CERVICAL LYMPH NODE <br />possibility of chronic lymphoid leukemia / small lymphocytic lymphoma<br />
  25. 25. INGUINAL NODE BIOBSY<br />Diffuse effacement of lymphnode architecture by monotonous population of neoplastic cells [lymphocytes]. The cells are small with scant cytoplasm noncleved centrally placed nucleus with open chromatin. The neoplastic cells are seen to infiltrate the adjacent perinodal pad of fat. Blood vessels are interspread with in neoplastic cells.<br />Impression<br /> Non Hodgkin lymphoma/ chronic lymphoid leukemia / small lymphocytic lymphoma<br />
  26. 26. Patient had trouble with crossmatching  possible Auto Immune Hemolytic Anemia<br />
  27. 27. Hematology opinion<br />Suggested<br />LDH <br />Hematocrit<br />To do Direct Coomb’s Test  to r/o AIHA<br />
  28. 28. Plan to start chemotherapy after blood investigation<br />But before we could start chemotherapy pt deteriorated and died of cardio respiratory arrest<br />
  29. 29. Final diagnosis<br />Small cell lymphoma infiltrating the liver causing portal hypertension and chylous ascites with possibly autoimmune hemolytic anemia.<br />
  30. 30. CHYLOUS ASCITES<br />Chylousascites is an uncommon clinical condition that occurs as a result of disruption of the abdominal lymphatics.<br />
  31. 31. CAUSES<br />Abdominal surgery<br />Abdominal trauma<br />Malignant neoplasms hepatoma, small cell lymphoma, retro peritoneal lymphoma<br />Spontaneous bacterial peritonitis [SBP]<br />Cirrhosis – upto 1%<br />Peritoneal dialysis<br />Abdominal tuberculosis<br />Carcinoid syndrome <br />Congenital defects of lacteal formation <br />
  32. 32. classification<br />True chylous ascites: fluid with high triglyceride content (>200mg%)<br />Chyliform ascites: fluid with a lecithin- globulin complex due to fatty degeneration of cells.<br />Pseudo chylous ascites: fluid that is milky appearance due to the pus<br />
  33. 33. Chylousascites diagnosed by<br />-The ascitic fluid triglyceride level is elevated in all pts with chylous ascites.<br />-TGL >110 mg/dl, >200 definite<br />-Elevated ascites : plasma triglyceride ratio [between 2.1 and 8.1]<br />Complication<br />Sepsis<br />Sudden death<br />
  34. 34. TREATMENT<br />Chylous ascites is a manifestation rather then a disease depends on the treatment of the underlying disease or cause<br />Supportive measures can relieve the symptoms such as repeated paracentesis, diuretic therapy, salt and water restriction<br />Low-fat diet with medium chain triglyceride<br />Octreotide is most likely effective<br />
  35. 35. Non-hodgkin's Lymphoma of the Liver<br />Lymphomatous infiltration of the liver is more common in non-Hodgkin's lymphoma (NHL) than in Hodgkin's<br /> disease. <br />Hepatic involvement with NHL has been described in liver biopsy specimens in up to 53% of cases (and an even higher percentage at autopsy), is more common with small-cell varieties than with large- cell types.<br />
  36. 36. Liver biochemical test results may be abnormal (primarily an increase in serum alkaline phosphatase), and hepatomegaly may be detected.<br />Rarely, NHL can present as a primary hepatic lymphoma. <br />Apart from human immunodeficiency virus–associated lymphomas, primary hepatic lymphoma has a better prognosis than NHL because of the possibility of cure with successful resection. <br />
  37. 37. Jaundice is rare in patients with NHL and in the past was considered a terminal occurrence. <br />Jaundice secondary to extrahepatic biliary obstruction is more common in NHL (1.2%) than in Hodgkin's disease (0.3%), and biliary obstruction occurs most commonly at the porta hepatis, although primary lymphomatous involvement of the bile ducts has been reported in rare cases. <br />In patients with NHL and jaundice, gallstones and pancreatic adenocarcinoma must be excluded. <br />
  38. 38. Treatment <br />Hepatic resection/Orthotopic liver transplant for primary hepatic NHL.<br />Chemotherapy for CLL/SLL with secondary hepatic involvement:<br />Fludarabine/cladribine is usually combined with an alkylating agent such as cyclophosphamide.<br />Alemtuzumab – a monoclonal antibody against CD52 is tried in refractory cases. <br />
  39. 39. Thank you<br />
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