Internal hernia in a patient with chylous ascites: a case report

Chylous ascites is a rare medical disorder in which chylous fluid leaks from the lymphatic system into the abdominal cavity. When a patient has a history of abdominal surgery, especially subtotal gastrectomy, it is crucial for the physician to remain vigilant regarding the risk of internal hernia, which may result in lymphatic blockage and subsequent chylous ascites.

A 70-year-old male admitted to our hospital complained of abdominal pain for 9 h. The patient had no obvious cause of abdominal pain, and the abdominal pain was not severe. The surgical history indicated a subtotal gastrectomy (Billroth II type) for a gastric ulcer that was conducted 20 years prior. CT scan revealed mild intestinal dilatation within the abdominal cavity and abdominal fluid accumulation. The diagnostic abdominal paracentesis was performed, revealing triglyceride levels that indicated the presence of chylous ascites. The clinicians opted for a conservative approach and executed percutaneous drainage. Two days later, the abdominal discomfort persisted, and around 600 mL of chylous ascites was being drained each day. Given that the prior conservative approach did not yield results, the subsequent course of action was laparoscopic exploration. An adhesive band was formed at the mesentery 1.5 meters from the Treitz ligament, accompanied by an internal hernia. The chylous fluid was drained, and the internal hernia was resected. The patient gradually resumed eating and was discharged after recovery.

Chylous ascites is diagnosed through paracentesis and triglyceride testing. In patients with a prior abdominal surgery, particularly those who have undergone subtotal gastrectomy, it is prudent to consider the possibility of an internal hernia, even in the presence of negative imaging results. Conservative management frequently proves inadequate, while laparoscopic exploration serves a dual purpose of diagnosis and treatment, facilitating adhesiolysis and hernia reduction.