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Thursday, 30 April 2020

ASCITITIC LIQUID OF UNKNOWN ETHOLOGY

Written by Ana María García Cano | Alba Arroyo Vega | Marta Rosillo Coronado

Figure. Appearance of the liquid before centrifugation (A), after centrifugation (B) and sparkling supernatant (C and D).

A 53-year-old patient with a diagnosis of stage IIIC high-grade serous carcinoma of the ovary, admitted to surgery for peritoneal carcinomatosis secondary to it, for biopsy and treatment of hyperthermic intraperitoneal chemotherapy (HIPEC).

In the course of the intervention, a large amount of milky-looking ascitic fluid is found, which is evacuated to a total of 4.9 liters. When in doubt about the origin and composition of the same, they send the sample for analysis to the laboratory.
The microbiological study ruled out the presence of microorganisms. In the biochemical study, 137 mg/dL cholesterol (<45 mg/dL), triglycerides 382 mg/dL (<110_mg/dL), LDH 1693 IU/mL (23-112 mg/dL), 6,1_mg proteins were highlighted/dL (0,8-3 mg/dL) and albumin 3,2 mg/dL (0,4-1,8 mg / dL).

The appearance of the liquid showed white-yellowish color and creamy consistency. After centrifugation, a white-yellowish liquid with foamy supernatant and clear white button was observed. Given this aspect, the possibility was raised that the liquid was of lymphatic origin.

Since there is no specific biochemical marker that evidences the presence of lymph, the presence of chylomicrons or triglycerides could be indicative of it1,2. Since in our laboratory, chylomicrons are not determined routinely, lipoprotein electrophoresis is considered the gold standard)3, the afore mentioned parameters were measured, including triglycerides and cholesterol. The presence of chylomicrons can be recognized visually in the upper part of the supernatant after centrifugation, where a thin white layer of creamy consistency appears. The triglyceride level of 382_mg/dL and cholesterol of 137 mg/dL, as well as the creamy-foaming aspect of the supernatant, are characteristic of the chylous origin of the liquid.

Chylous ascites is characterized by a triglyceride number above 200 mg/dL, proteins >3 g/L, leukocytes with a predominance of lymphocytes, as well as cholesterol levels <220 mg/dL4. Chylous effusions may have their origin in a traumatic rupture, a fistula of the thoracic duct, a lymphatic obstruction or a carcinoma1. The appearance of lymph is usually yellowish-white, thick and colorless. Its composition is mostly fat. Chylous ascites is a rare finding, associated in most cases with neoplastic processes after surgery, mainly in those cases in which retroperitoneal lymph node dissection has occurred.
 

REFERENCES

  1. Piedra GV, Campuzano EG, Queral LA, Ortega AG, Holgado AH, Segarra XN, et al. Identificación de líquidos biológicos de origen desconocido. Rev Lab Clínico. 2018;11(4):209-16.
  2. Valcárcel Piedra G, Guillén Campuzano E, Altimira Queral L, Galán Ortega A, Hernando Holgado A, Navarro Segarra X, et al. Identificación de líquidos biológicos de origen desconocido. Rev Lab Clínico. octubre de 2018;11(4):209-16.
  3. Bhardwaj R, Vaziri H, Gautam A, Ballesteros E, Karimeddini D, Wu GY. Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment. J Clin Transl Hepatol. 28 de marzo de 2018;6(1):1-9.
  4. Ares J. Ascitis quilosa postlaparoscopia abdominal; revisión y descripción de un caso. Nutr Hosp. 1 de abril de 2015;(4):1874-8.
 

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