chylous Ascites

Chylous Ascites

Go to M. to Elisa Jorda, MD, MPH
Edy Nacarapa, MD
Elsa Zitha, Tec-med
Sergio Ussivane, RN

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1. progressive abdominal distension


Patient, NID CK17471, 35 years old, male, mesti ç o, BMI 19.66 kg / m 2 , comes the emergency room with abdominal distension history of gradual onset of ha 1 month, painless, associated with anorexia, weakness, nausea, fever, night sweats, edema of the extremities and hydrocele painless. Symptoms tend to worsen with evolution ction the recent ha a week of dyspnea, accompanied by weight gain, and feeling of early satiety. Denies abdominal pain, testicular pain, diarrhea, oliguria, hematuria, pyuria, chyluria, cough, or fainting.

History of hospitalization in the past 5 months past due to the diagnosis of abdominal TB and HIV / AIDS WHO III, which had optimal clinical evolution. He was discharged, but this in Chemotherapy with tuberculostatic I ha Category 5 months, the maintenance phase with INH and PZA. And four months on ART ha with d4T +3 TC + EFV. Nega-orchitis Epididymo previous Laparatomies, abdominal biopsies, peritoneal dialysis. Nega similar family history.

From social point of view it is a driver by profession, with habits to travel throughout the country Rovuma to Maputo ha about 10 years, also has habits of consumption of alcohol and tobacco.

Physical examination of entry: State general severe dyspnea that worsens with effort ç the gait, massive anasarca and generalized lymphadenopathy, pale mucous membranes, no jaundice, no cyanosis, no petechiae.

Vital Signs: T = 37.4 the C, HR = 142 bpm ↑ ↑ , FR = 43 ↑ ↑ , TA: 90/50 mmHg ↓ ↓, Weight = 80 Kg

Mouth without white plates, and the hard palate without abnormality. The respiratory apparatus reveals a murmur bladder uneven, it is quite satisfying to levels of 2/3 middle and upper symmetrically, however absent in the lower 1/3 bilaterally, but with more emphasis on the right side, and no rales. The apparatus reveals cardiac heart sounds B1 and B2 normal sounds, no murmurs. The abdomen was distended features, tense, abdominal wall edema, hepatosplenomegaly one of hard palpa ction to the kidneys not palpable, dullness mobile diffuse positive, negative Blumberg, Murphy renal negative. The genitourinary hydrocele reveals a painless height of 1/3 average femoral and scrotal wall edema. Musculoskeletal system without abnormality. The Neurological stiffness without nuchal, reflexes and normal sensitivity.

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2. Differential Diagnosis

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a) Malignant Lymphoma : epidemiologically considered primary cause of Chylous Ascites, the story reveals the patient to treat a chronic disease, so further tests need of an abdominal ultrasound or abdominal CT-Scan that would be favorable, as well as a biopsy.

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b) Abdominal TB complicated: the historical antecedent of Diagnosis of abdominal TB, inpatient weighs considerably to conclude that this is a complicated ction o, and therefore ‘must consider that the abdominal distension had devel ction months to a considerably associated weight gain with progressive extension to the scrotum, hydrocele characterized by recent, and both abdominal wall edema and scrotal. These findings concluded that the hydrocele is extension of abdominal ascites, but not the reverse. One of the strong pathophysiological hypotheses that Chylous Ascites, due to the fact that TB Abdominal cause hypertrophy and ganglionic Paraortica paravenacava such ganglia by itself may be in the form of abscesses ganglion intrabdominal or not, may cause mechanical compression of the thoracic duct or its rupture, both the compression of the thoracic duct and the rupture may ocassionar lymph drainage for the space ç the peritoneal.

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c) Lymphangiectasis intestinal: occurs either as a primary or a secondary form. Primary lymphangiectasia is characterized by diffuse ectasia or localized intestinal lymphatic system and is often diagnosed at a young age. The secondary form of the disease occurs with conditions that produce impaired lymphatic flow, the causes are heart failure (congestive heart failure or constriction), neoplastic (lymphoma), or structural (retroperitoneal fibrosis). Patients present with marked edema, diarrhea, nausea and vomiting, too, chylothorax and chylous ascites may be present. Steatorrhea can be simultaneous with a protein-losing enteropathy. Laboratory findings include a decrease in the level of plasma proteins and lymphocytopenia, which may affect cellular immunity. Endoscopically dot white spots can be seen in gut mucosa, marked dilation shows histological examination of the lacteals. Abnormalities of the lymphatic system can also be evaluated with contrast lymphangiography or nuclear scintigraphy after a high fat load. The state with the loss of proteins can be verified with a test clearance alpha-antitrypsin. For the case of the clinical history of the patient he denies episode of diarrhea, which could explain for protein-losing enteropathy and steatorrhea.

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d) Filariasis: lymphedema and elephantiasis and hydrocele

Chronic lymphedema progresses to elephantiasis most commonly affects the legs. The arms, scrotum, penis, vulva and breasts may also be affected more rarely. Following recurrent episodes of acute attacks, pitting edema, and edema after chronic depressions with no loss of skin elasticity and fibrosis develops. Actuamente edema of the lower limbs of this patient has Gode Positive what underlies that have not yet lymphedema is a chronic, may be treated further evolutionary stage for elephantiasis hypothetically as chronic lymphedema of filariasis is characterized by a swelling hard, which in turn for several years, without swelling becomes depressions with the thickening and loss of elasticity. Progression leads to elephantiasis evident with folds of skin, and dermatosclerosis papillomatous lesions and may be cumplicar with vegeta tio es fungal and bacterial infections in the dermis.

Hydrocele is the most common chronic manifestation of lymphatic filariasis. It is the result of the accumulation of light straw-colored liquid in the sac around the testicles. The initiation may silent, ie without the accompaniment of acute or may be preceded by one or more attacks funiculitis or epididymoorchitis. After the first few episodes acute swelling around the testicles usually disappears completely, but over the years the tunica vaginalis becomes thick and there is progressive increase of hydrocele. Most cases are unilaterally, but bilateral hydrocele, often with different sizes on both sides are common. Rarely, the fluid may have a milky sap if a lymphatic vessel ruptured pouring in to form a hydrocele chylocele. In clinical trials, hydrocele is classified according to the stage of development and size. The terror in the clinical history of the patient lies in the fact that your hydrocele be evolution ction in the short period since one month one month does not justify the filariasis that hydrocele could reach the third medium of the femur, the other detail is that the patient denies qualqer testicular pain last justifying a epidimites, and with the aggravating patient show significant regression of hydrocele after therapeutic paracentesis.

Lab test

Hemograma
WBC 8.7 x 10
Lym 9.5 %
0.8 x 10
Neut 83.1 %
7.3 x 10
Mxd 7.4 %
7.3 x 10
Hgb 10.1 g/dl
Hct 33.1 %
MCV 84.4 fL
MCHC 30.5 g/dl
PLT 119 x 10
RDW 15 %

CD4 162 cells/

Bioquimica

Interpretacao Resultado unidades Range
Gluc ↓ 65.18 mg/dl 75.00 – 1150
Albumina ↓↓ 17.68 g/l 38.00 – 51.00
Creatinina 0.59 mg/dl 0.70 – 1.40
Prot Totais ↓↓ 37.27 g/l 66.00 – 87.00
Ureia 18.24 mg/dl 10.00 – 50.00
Bil Total 0.33 mg/dl 0.00 – 1.50
Bil Directa 0.22 mg/dl 0.00 – 0.25
GOT 42.43 U/L 0.00 – 37.00
GPT ↑↑ 96.12 U/L 0.00 – 42.00
Triglicerideos 76.41 mg/dl 0.00 – 150.00

Microbiologia do Liquido Quiloso

Gram Neg
GIEMSA Neg
BK Neg

Citoquimica do Liquido ascitico Quiloso

Cor Lactea e nublado
Bil neg
Urobilinogenio normal
Ketones Neg
ASC Neg mg/dl
Gluc 150 mg/dl
Prot 100
Blood Neg
pH 8
Nit Neg
Leu Neg
SG 1.005

Características esperadas de fluido ascítico em ascite quilosa

Cor Láctea e nublado
Nível de triglycerides Acima de 200 mg / dL
A contagem de celulas Acima de 500 (predominância de linfócitos)
Proteína total Entre 2,5-7,0 g / dL
SAAG Abaixo de 1,1 g / dL *
Colesterol Baixa (ascite / Soro 40 UI / litro) em casos de pancreatite aguda ou aguda

Conduta

Paracentese Terapeutica de emergencia: 2500 mL
Seguimento 3/3 dias paracentese 2000 mL, regime ambulatorio.

aguarda transferencia para Hospital Central de MAputo