NONCHYLOUS LYMPHATIC ASCITES AFTER APPENDECTOMY
A few days after appendectomy, increasing amounts of serous
fluid within the abdominal cavity were noted in an 11-year-
old-boy. Explorative laparotomy done 2 weeks after appen-
dectomy revealed 2 L of fluid within the peritoneal cavity.
Histological and bacteriological studies of the fluid showed no
signs of an inflammatory or malignant process.
Fluid analysis revealed a high protein content and lym-
phocytosis with positive acidic phosphatase staining, strongly
suggesting chylous ascites. However, triglycerides remained
low even after a fat-containing oral test meal.
Suspecting leakage of lymphatic fluid from a possibly
lacerated right lumbar ductus, we injected methylene blue
intradermally into the toe web spaces. Two hours later, the
drained abdominal fluid turned blue-green, indicating leakage
of lymphatic fluid into the abdominal cavity. Subsequently,
lymphangiography was performed not only to identify the
exact site of the leak (Figure), but also to attempt sealing of
the lacerated site.
After lymphangiography, losses of lymphatic fluid
steadily decreased and ceased after 10 days.
Figure. Lymphangiography showing leakage of contrast medium in the
abdominal cavity through a laceration of the right lumbar ductus.
Accumulation of lymphatic fluid in the abdominal cav-
ity is a rare complication of abdominal surgery caused by
incidental laceration of lymphatic vessels. Chylous ascites has
been described after various surgical interventions,1 including
aortic surgery,2 Nissen fundoplication,3 anterior lumbar sur-
gery,4 and nephrectomy.5 Although abundant lymphatic ves-
sels are located close to the appendix, lymphatic ascites after
appendectomy has not yet been reported.
We failed to demonstrate an increase in triglycerides
after a fat-containing test meal. This finding is explained by
the fact that the site of injury was located distally from where
the intestinal truncus joins the lumbar truncus.
This case further illustrates that lymphangiography not
only is a diagnostic tool, but also may have a therapeutic
effect. After aquaeous hydrolysis, the oily contrast medium
induces inflammation at the site of outflow, which can seal
the laceration.
Eva Landmann, MD
Wigbert Rau, MD
Maria Vollerthun, MD
Ludwig Gortner, MD
Stefan Alexander Wudy, MD
Department of General Pediatrics and Neonatology
Center of Child and Adolescent Medicine
Department of Radiology and Department of Surgery
Justus-Liebig-University Giessen, Germany
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10.1016/j.jpeds.2006.05.034
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