CHYLOUS ASCITES-A PRESENTATION OF GASTRIC LYMPHOMA

A 47-year-old Bangladeshi male was admitted in a medicine unit of Dhaka Medical College Hospital with the complaints of abdominal discomfort for one year, loose mucoid stool associated with anorexia, nausea, vomiting and weight loss for four months and gradual swelling of abdomen for one month. For these complaints he was investigated and was treated with Anti TB drugs on trial basis prior to hospitalization without any significant improvement. He gave no history of fever, cough, jaundice, haematemesis or melaena. Patient was mildly anaemic and examination of abdomen revealed ascites. There was no lymphadenopathy or hepatosplenomegaly.

proximal and mid body along the greater curvature with irregularity and discrete shallow ulcers in the rest of the mucosa in these areas.Biopsy was obtained and the histopathology report revealed dense accumulations of small lymphocytes in the lamina propria extending into the submucosa, findings were suggestive of diffuse non Hodgkin lymphoma, intermediate grade.H. pylori IgG was negative.
The patient was given high protein and low fat diet and was administered chemotherapy.He received 4 th cycle of chemotherapy prior to writing this report and is due for his 5 th cycle.His condition improved and the ascites disappeared.

Discussion:
Chylous ascites is a rare clinical condition.The extravasations of the milky chyle in to the peritoneum denovo or into a preexisting ascites leads to formation of chylous ascites.This condition is diagnosed when the content of the triglyceride in the ascitic fluid is >200 mg/dl. 1 There is a wide range of causes leading to such a condition.De novo formation is mostly due to trauma.Abdominal surgery usually of the retro peritoneum 2 and liver transplantation 3 are common causes in the developed world.While abdominal tuberculosis 4,5,6 and filariasis 5,6 are the leading causes of chylous ascites in the developing countries.CMV infection 7 has also been reported in one case report.Up to 0.5%-1% patient suffering from cirrhosis of liver may present with chylous ascites. 8,9 alignant neoplasms such as small bowel lymphoma 10 , retroperitoneal lymphoma, hepatoma and bowel angiosarcoma has also been reported.In fact in the past this was one of the major causes as reported by Kelly and butt of the Mayo clinic where they found 62 of 71 reported cases were secondary to malignancy. 11The pathophysiology in such cases is mostly obstruction of the lymphatic channels.Other than these, constrictive pericarditis 12 , Pancreatitis 13 , spontaneous bacterial peritonitis, pelvic irradiation 14 , peritoneal dialysis, carcinoid syndrome and congenital defects of lacteal formation have all been linked to the etiology of chylous ascites.
The symptoms and signs are usually similar to those of ascites and in majority of cases, the diagnosis is not suspected till paracentesis.A prospective study found 45 malignant ascites patients(10%) out of 448 patients having ascites and 6.7% of them had chylous ascites which was diagnosed on the basis of milky white colour, triglyceride content and cytology. 15The common dilemma is to differentiate between chyle and pus, the later usually having a high acute inflammatory cell count and a high serum to ascitic fluid albumin gradient.Abdominal USG and CT may help in identifying lymph nodes and other mass.Peritoneal biopsy is required to confirm the diagnosis of tuberculosis. 16e prognosis in case of lymphoma with chylous ascites could not be known.The treatment modality is that of lymphoma itself.Only a few studies have mentioned the management of this sort of ascites per se. 17Nutritional status in this case required special attention as mentioned in various studies.High protein and low fat diet with medium chain triglyceride (MCT) is the first choice for the improvement of ascites and if this fails then TPN along with fasting remains the option out, as fasting reduces intestinal lymph flow. 18,19

Conclusion:
In Bangladesh when ever we get a patient of ascites, the first diagnosis that strikes our mind is cirrhosis.Following paracentesis, if the fluid is chylous, filariasis is what we think of.After exclusion of filariasis, we should also keep in mind lymphoma when chylous ascites is found in a patient with no apparent diagnostic clue.

Fig - 2 :Fig - 3 :
Fig -2: Endoscopy showed nodular swelling and thickening of gastric folds in the proximal and mid body along the greater curvature with irregularity and discrete shallow ulcers in the rest of the mucosa in these areas