B0048 - Chylous Ascites (CA) From Necrotizing Pancreatitis (NP): A Case Series

Monday, October 24, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

David Jonason, MD

University of Minnesota Medical Center
Minneapolis, MN

David Jonason, MD, Amanda Hjeltness, PA-C, Gaurav Suryawanshi, MD, Guru Trikudanathan, MD
University of Minnesota Medical Center, Minneapolis, MN

Introduction: Chylous ascites (CA) occurs from obstruction or perforation of the peritoneal and retroperitoneal lymphatic system. Common etiologies include malignancy, cirrhosis and infections. On rare occasion, CA may be a consequence of necrotizing pancreatitis (NP). We report a case series of five NP patients who developed CA as a late sequalae.

Case Description/Methods: Five patients (males-2, mean age- 65 years) hospitalized at our institution between 2019-2022 with necrotizing pancreatitis developed CA after a median 85 (IQR 80-169) days from NP. NP etiologies varied as per Table 1. All patients were endoscopically treated for infected walled off necrosis (WON) and two required percutaneous and surgical intervention a median 55 days (IQR 17-108) prior to CA development. CA presentation was variable. Patient A noted weight gain and painless abdominal distention with incidental new ascites on CT scan prior to scheduled endoscopic necrosectomy. Patient B reported fevers and abdominal pain and was found to have CA in the setting of suppurative cholecystitis and WON. Patient C had clinical concerns for secondary bacterial peritonitis (SBP) from a retroperitoneal abscess that initially improved with antibiotics but subsequently developed into CA. Patient D acquired CA during a prolonged NP hospitalization requiring abdominal washout and drain placement for loculated pancreatic ascites. Lastly, patient E developed CA while treated in the ICU for E.coli bacteremia and WON. The mean ascites triglyceride level was 644 mg/dL (IQR 463-750). No malignant cells were found on cytology. One patient had a SAAG >1.1. Lymphoscintigraphy failed to show lymphatic leaking in cases used. All patients were treated with a high protein and low fat diet with medium chain triglyceride (MCT) supplementation. One patient received octreotide and one was placed on TPN. Two patients had persistent CA at three month follow up, which resolved by six months. Three patients ultimately died over the next year due to complications of sepsis (n=2) and respiratory failure (n=1). One patient is still being followed.

Discussion: Chylous ascites is a rare complication of NP with an unknown natural history. The need for intervention for NP and development of systemic infection may increase this risk, as was common among our patients. Dietary modifications yielded variable outcomes in our group. Providers should be conscious of this potentially fatal complication.

Parameter	Patient A	Patient B	Patient C	Patient D	Patient E
Gender	Male	Male	Female	Female	Female
Age, years	64	39	43	66	68
Etiology of NP	Idiopathic	HTG	HTG	Biliary	Biliary
NP interventions	Endoscopic	Endoscopic	Endoscopic, percutaneous, surgical	Endoscopic, percutaneous, surgical	Endoscopic
Indication for intervention	Infected WON	Infected WON	Infected WON	Infected WON	Infected WON, GOO
Days from NP to Chylous Ascites	169	80	1757	15	85
Days from last mechanical intervention to CA	143	55	108	14	17
Positive lymphoscintigraphy	No	No	No	No	No
Ascites triglyceride, mg/dL (IQR)	714	835	463	750	458
SBP	No	No	Yes	Yes	Yes
Malignancy	No	No	No	No	No
SAAG >1.1	No	Yes	No	No	No
MCT supplementation	Yes	Yes	Yes	Yes	Yes
Octreotide	No	No	No	No	Yes
TPN	No	No	No	Yes	No
Persistent CA (3 months)	n/a	Yes	No	No	Yes
Duration of CA, days	n/a	180	7	7	180
Cause of death	None	Sepsis	Sepsis	Sepsis, Respiratory failure	None

Table: Characteristics, Management and Outcomes of Patients with Chylous Ascites.

NP, necrotizing pancreatitis; HTG, hypertriglyceridemia; WON, walled off necrosis; GOO, gastric outlet obstruction; CA, chylous ascites; SBP, spontaneous bacterial peritonitis; SAAG, serum albumin-ascites gradient; MCT, medium chain triglycerides; TPN, total parenteral nutrition.

Disclosures:

David Jonason indicated no relevant financial relationships.

Amanda Hjeltness indicated no relevant financial relationships.

Gaurav Suryawanshi indicated no relevant financial relationships.

Guru Trikudanathan: Boston Scientific Corporation – Consultant.

David Jonason, MD, Amanda Hjeltness, PA-C, Gaurav Suryawanshi, MD, Guru Trikudanathan, MD. B0048 - Chylous Ascites (CA) From Necrotizing Pancreatitis (NP): A Case Series, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.