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      Fístula quiloperitoneal en gestante a propósito de un caso

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          Abstract

          conducto torácico, el cual drena su contenido a la circulación venosa a nivel de la vena subclavia izquierda. La fístula quilosa se define como la perdida de linfa desde los vasos linfáticos, típicamente acumulado en la cavidad abdominal y/o torácica, ocasionalmente manifestada como una fístula externa.(120) El tratamiento conservador de la fístula quilosa está recomendado en la mayoría de los pacientes y va a estar determinado por las fístulas con gasto elevado que causan alteraciones fisiológicas tempranas, por lo que el tratamiento debe ser agresivo. Las fístulas quilosas de origen tumoral son de difícil manejo, el tratamiento es más exitoso si estas se presentan luego de un trauma o cirugía. Para mejorar la efectividad del tratamiento conservador, se ha sugerido asociar a las medidas antes señaladas el uso de somatostatina o sus análogos. El tratamiento quirúrgico es abordado cuando la terapia conservadora falla (40%).99 Se presenta el caso de femenina de 39 años, proveniente del Estado Nueva Esparta, sin antecedente patológicos conocidos, IV gesta, III para a quien se le realizo cesárea de emergencia a las 34 semanas por feto con poli hidramnios y al abordar cavidad abdominal hay la presencia de liquido de aspecto lechoso del cual obtienen 3000cc aprox., extraen el feto el cual estaba en condición estable, revisan cavidad abdominal sin evidenciar patología. Es egresada en condición estable, y consulta a los 7 días por aumento de volumen abdominal. En vista de esto es referida a nuestro centro donde se realizan diversos estudios como laboratorio que solo reportó anemia (Hb 10), marcadores tumorales (alfa feto proteína, Ca 19-9, CEA) negativos, pruebas especiales para descartar trastorno de coagulación resultaron negativos, Tomografía de tórax-abdomen y pelvis cuya conclusión fue derrame pleural bilateral escaso y ascitis. Ecodoppler de vena porta, supra hepáticas y esplénica normal, estudios endoscópicos normales, el cito químico del líquido reportó triglicéridos en 652/dl, en vista de estos hallazgos se re interroga a la paciente y refiere que durante el embarazo presento dos caídas cuyo traumatismo se localizo en región costal derecho, y revisando la literatura se decidió solicitar linfoganmagrafía cuyo resultado concluyó Hipercaptación persistente en tiempo, localizada en epigastrio, con área heterogénea difusa, que impresiona extravasación de linfa subhepática en probable relación a fistula quilo peritoneal, con éste resultado se inicio tratamiento médico a base de octreotide, diuréticos de asa, nutrición parenteral con triglicéridos de cadena mediana, dieta absoluta durante 4 meses con mejoría del cuadro. Actualmente paciente sin ascitis y asintomática, manteniendo dieta baja en grasa saturadas.

          Translated abstract

          The lymphatic system represents a vast network of capillaries and vessels distributed throughout the body, which converge at the thoracic cavity to a largest single structure, the thoracic duct, which drains its contents into the venous circulation to the left subclavian vein. Chylous fistula is defined as a loss of lymph from the lymphatic vessels, typically accumulated in the abdominal cavity and/or cage, occasionally manifested as an external fistula. (120) Conservative treatment of chylous fistula is recommended in most patients and shall be determined by high output fistulas causing early physiological changes, so treatment should be aggressive. Tumoral chylous fistulas are difficult to manage; treatment is more successful if these appear after trauma or surgery. To improve the effectiveness of conservative treatment, it has been suggested to associate the use of somatostatin or its analogs with the above mentioned measures. Surgical treatment is addressed when conservative therapy fails (40%). We present a case of a 39 years-old female, from the state of Nueva Esparta - Venezuela, with no known medical history, GESTA IV, III who underwent emergency cesarean section at 34 weeks due to fetus with polyhydramnios. When approaching the abdominal cavity they found a milky fluid of which they obtained 3000cc approx.; they took out the fetus which was in stable condition and examined the abdominal cavity without evidence of any pathology, whatsoever. She was discharged in stable condition, and comes back to consult at 7 days after due to increased abdominal volume. For this reason, she was referred to our center where several studies are made, such as laboratory studies which only reported anemia (Hb 10), tumor markers (alpha fetoprotein, Ca 19-9, CEA) negative, special tests to rule out clotting disorder were negative; negative immunological profile (ANCA, ANA, AMA, AML), CT Scan of the chest-abdomen and pelvis which concluded bilateral small pleural effusion and ascites. Normal Echo-Doppler of portal, suprahepatic and splenic veins, normal endoscopic studies, the cytochemical analysis of the fluid showed triglycerides in 652/dl, in view of these findings, the patient is again interrogated and reports that during pregnancy she fell down twice with consequence of trauma in the right costal region. Reviewing the literature, it was decided to ask for a lymphoscintigraphy, which concluded persistent hypercaptation, located in the epigastrium, with diffuse heterogeneous area that impresses subhepatic lymph extravasation probably related to peritoneal chylous fistula; with this result medical treatment based on octreotide, diuretic loops, parenteral nutrition with medium-chain triglycerides and absolute diet for 4 months was begun, with improvement of the condition. Currently, the patient is without ascites and asymptomatic; maintaining a low saturated fat diet.

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          Chylous Ascites

          Context: Chylous ascites is the accumulation of milky chyle in the peritoneal cavity. Chylous ascites has been reported after surgeries like abdominal aortic aneurysm repair, radical gastrectomy, duodenectomy, nephrectomy and Wilm's tumor resection. Our literature search did not reveal any reports of chylous ascites after a gastric ulcer resection. We report about an elderly woman with a rare complication of chylous ascites after an emergent surgery for a perforated gastric ulcer. Case Report: A 70-year-old woman developed sudden respiratory distress on 5th post-operative day after an elective C3-C7 cervical discectomy and fusion. Her past medical history was significant for cervical spondylosis. The Computed Tomography (CT) scan of the chest revealed air under the diaphragm suspicious for hollow viscus perforation. She underwent an emergent surgery for drainage of hematoma in the neck along with an emergent laparotomy to repair a large perforated gastric ulcer distal to the gastro-esophageal junction. The patient had worsening of abdominal distention on 4th post-operative day. The CT scan of abdomen showed fluid collection in the abdomen. The abdominal drain revealed large amount of serous milky fluid at the rate of 1500 ml per day. The fluid analysis showed that the triglyceride level was 170 mg/dl and cholesterol level was 15 mg/dl. The fluid cultures did not grow any organism. She responded to treatment with octreotide and a diet of medium chain triglyceride oil. Conclusion: Any obstruction or damage to the lymphatic channels results in chylous ascites. Lymphomas, metastatic malignancies, and abdominal surgeries commonly cause chylous ascites. Ascitic fluid triglyceride level greater than 110 mg/dl is diagnostic of chylous ascites. Chylous ascites is a rare complication of a peptic ulcer resection which can be managed effectively with octreotide.
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              Chylous Ascites

              (2024)
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Journal
                gen
                Gen
                Gen
                Sociedad Venezolana de Gastroentereología (Caracas )
                0016-3503
                September 2010
                : 64
                : 3
                : 206-207
                Affiliations
                [1 ] Hospital Militar Dr. Carlos Arvelo Venezuela
                [2 ] Hospital Militar Dr. Carlos Arvelo Venezuela
                [3 ] Hospital Militar Dr. Carlos Arvelo Venezuela
                Article
                S0016-35032010000300011
                f9c86f20-defa-4be1-af5f-d80638e74fe0

                http://creativecommons.org/licenses/by/4.0/

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                Product

                SciELO Venezuela

                Self URI (journal page): http://www.scielo.org.ve/scielo.php?script=sci_serial&pid=0016-3503&lng=en

                Chyloperitoneum,Fistula quilo peritoneal,ascitis quilosa

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