Chylothorax in a Young Woman With Crohn Disease.

Chylothorax, which accounts for 1% to 3% of pleural effusions, typically results from either surgery (traumatic) or underlying malignancy (nontraumatic). Less common causes of nontraumatic chylothorax are numerous and include congenital lymphatic abnormalities, connective tissue diseases, cirrhosis, and infection, among others.1 We describe what appears to be the first reported case of chylothorax caused by chylous ascites in Crohn disease. This case highlights the importance of using diagnostic evidence to link new symptoms to preexisting diseases whenever possible, as well as the systemic nature of Crohn disease.

Beyond the norm: Illuminating eosinophilic ascites with 2 rare and intriguing cases.

Eosinophilic ascites (EA) is a rare and enigmatic disorder characterized by elevated eosinophil counts in peritoneal fluid, commonly associated with eosinophilic gastroenteritis (EGE), hypereosinophilic syndrome (HES), and parasitic infections. Here, we present two cases of EA diagnosed and managed in our gastroenterology department. Case 1: A 45-year-old male presented with diffuse abdominal pain and distension. Imaging revealed septate abdominal ascites, prompting exploratory laparoscopy. Ascitic fluid analysis showed eosinophil predominance, leading to an EA diagnosis. The patient was treated with oral Albendazole, resulting in a favorable outcome. Case 2: A 52-year-old female complained of abdominal pain with alternating diarrhea and constipation. Imaging unveiled moderate ascites, pyloro-duodenal inflammation, and wall thickening. Eosinophilic leukocytosis prompted empirical treatment, yielding a positive response. In conclusion, diagnosing EA involves a combination of histological and laboratory methodologies. Corticosteroids emerge as the primary therapeutic avenue, with the imperative of eradicating parasitic infections before initiation. This study underscores the critical role of education in mitigating the risk of parasitic infections.

Pseudotumoral pelviperitoneal tuberculosis mimicking ovarian cancer: A case report.

Tuberculosis is a rare but treatable infectious disease that continues to pose a significant health issue in regions with high prevalence. Its abdominopelvic localization can mimic advanced ovarian cancer, leading to diagnostic challenges. This report describes the case of a 33-year-old woman who was admitted to the gastroenterology unit with ascites, peritoneal thickening, and an ovarian mass on imaging. The diagnosis of abdominopelvic and peritoneal tuberculosis was confirmed after laparoscopy. The patient underwent antitubercular chemotherapy and showed clinical improvement.

Patient-derived acellular ascites fluid affects drug responses in ovarian cancer cell lines through the activation of key signalling pathways.

Malignant ascites is commonly produced in advanced epithelial ovarian cancer (EOC) and serves as unique microenvironment for tumour cells. Acellular ascites fluid (AAF) is rich in signalling molecules and has been proposed to play a role in the induction of chemoresistance. Through in vitro testing of drug sensitivity and by assessing intracellular phosphorylation status in response to mono- and combination treatment of five EOC cell lines after incubation with AAFs derived from 20 different patients, we investigated the chemoresistance-inducing potential of ascites. We show that the addition of AAFs to the culture media of EOC cell lines has the potential to induce resistance to standard-of-care drugs (SCDs). We also show that AAFs induce time- and concentration-dependent activation of downstream signalling to signal transducer and activator of transcription 3 (STAT3), and concomitantly altered phosphorylation of mitogen-activated protein kinase kinase (MEK), phosphoinositide 3-kinase (PI3K)-protein kinase B (AKT) and nuclear factor NF-kappa-B (NFκB). Antibodies targeting the interleukin-6 receptor (IL6R) effectively blocked phosphorylation of STAT3 and STAT1. Treatments with SCDs were effective in reducing cell viability in only a third of 30 clinically relevant conditions examined, defined as combinations of drugs, different cell lines and AAFs. Combinations of SCDs and novel therapeutics such as trametinib, fludarabine or rapamycin were superior in another third. Notably, we could nominate effective treatment combinations in almost all conditions except in 4 out of 30 conditions, in which trametinib or fludarabine showed higher efficacy alone. Taken together, our study underscores the importance of the molecular characterisation of individual patients' AAFs and the impact on treatment resistance as providing clinically meaningful information for future precision treatment approaches in EOC.

Portal hypertension and emergency care.

OBJECTIVE: Aim: To evaluate the peculiarities of the course of complications and the provision of care for portal hypertension associated with the development of diureticresistant ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and variceal bleeding. PATIENTS AND METHODS: Materials and Methods: This research is based on a review of the literature in PubMed, CrossRef, Google Scholar sources on complicated portal hypertension. Such complications of portal hypertension as spontaneous bacterial peritonitis, ascites, hepatorenal sуndrome, variceal bleeding caused by sinistral portal hypertension are considered. The effectiveness of interventional treatment methods and laparoscopic surgical interventions has been demonstrated. CONCLUSION: Conclusions: Diagnosis and treatment of patients with complicated portal hypertension requires a multidisciplinary approach, which is due to the diverse pathophysiological process of portal hypertension. The possibilities of providing emergency care to this category of patients depend on the level of medical training of the staff, the possibilities of medical and technical support in the provision of interventional care, the ineffectiveness of which necessitates surgical treatment using minimally invasive technologies.

Eosinophilic ascites and enteritis: a neglected case report from Vietnam.

Eosinophilic gastroenteritis poses a significant diagnostic challenge, particularly in developing countries, where the awareness of this condition may be limited. Here, the case of a patient in her early 30s, who presented with recurrent episodes of abdominal pain and diarrhea, is reported. Initial standard laboratory investigations revealed normal complete blood counts and elevated total serum immunoglobulin E levels. Upper and lower endoscopic evaluations with systemic biopsies did not reveal any significant abnormalities. However, computed tomography revealed a thickened small intestine wall, halo signs, and mild ascites. Analysis of the ascitic fluid confirmed eosinophilia. These findings prompted a diagnosis of eosinophilic gastroenteritis. The patient responded well to a targeted elimination diet, corticosteroids, and antileukotriene medication. The present case emphasizes the importance of considering eosinophilic gastroenteritis in the differential diagnosis of patients who present with abdominal pain and eosinophilic ascites.

Navigating the Labyrinth: Chylothorax and Chylous Ascites Unveiled After Abdominal Surgery for an Exceptionally Rare Tumor.

Schwannomas, originating from the Schwann sheath of peripheral or cranial nerves, are rare tumors commonly found in the head and neck or extremities. Adrenal schwannomas, however, are exceedingly rare, accounting for less than 1% of all adrenal tumors. Here, we present a case of a 31-year-old Caucasian woman diagnosed with an adrenal schwannoma, which was incidentally discovered during imaging studies for an unrelated issue. Following laparoscopic adrenalectomy, the patient developed chylous ascites (CA) and coexistent chylothorax, posing a diagnostic challenge and necessitating a multidisciplinary approach to management.

Fetal Urinary Ascites From Bladder Rupture: A Rare Complication of Posterior Urethral Valve.

Prenatal ultrasonography (USG) plays a crucial role in diagnosing fetal urinary tract anomalies and distinguishing between lower urinary tract obstructive (LUTO) and neurological causes (seen with spinal dysraphism, myelomeningocele, meningocele, and sacral agenesis) of urinary bladder distension. Fetal urinary ascites, a rare but severe complication, can result from bladder rupture associated with obstructive uropathy such as posterior urethral valves (PUV). This case study presents a rare instance of fetal urinary ascites due to PUV detected during prenatal ultrasonography at 20 weeks of gestation (WOG). By highlighting this uncommon but clinically significant condition, we aim to enhance the understanding and management of similar cases in clinical practice.

Massive chylous pleural effusion and protein­losing enteropathy caused by mesenteric panniculitis: A case report.

Mesenteric panniculitis (MP), also known as sclerosing mesenteritis, is a rare idiopathic condition characterised by chronic inflammation and fibrosis in the mesentery. While small amounts of chylous ascites due to lymph drainage obstruction are not rare in patients with MP, massive ascites is a rare complication. Moreover, protein-losing enteropathy (PLE), a rare intestinal condition of uncompensated plasma protein loss, can occur in patients with MP. To the best of our knowledge, the present study is the first to report MP with massive chylous pleural effusion and PLE in a 56-year-old male presenting with dyspnoea at Osaka Medical and Pharmaceutical University Hospital (Osaka, Japan) in March 2023. Approximately 5 years prior, the patient noticed systemic oedema, transient abdominal pain and fever and weight loss, and was diagnosed with chylous ascites and PLE by abdominal paracentesis and endoscopic examination of the small intestine. Although initial prednisolone (20 mg/day) administration improved the oedema gradual and uncontrolled fluid buildup was observed. Computed tomography revealed pneumothorax, bilateral massive pleural effusion, and pneumonia. Despite extensive antibiotic therapy [voriconazole (300 mg, twice/day), Ampicillin/Sulbactam (3 g x 4/day), and Vancomycin (1,000 mg x 2/day)], the patient succumbed to respiratory failure 1 month later. Autopsy revealed massive chylous ascites, pleural effusion and the presence of thickened and calcified nodules in the mesentery. Histopathological examination showed diffuse fat necrosis with fibrosclerosis, calcification and lymphocytic infiltration within the mesentery. Therefore, a definitive diagnosis of MP was made. The present case highlighted the importance of considering MP as a differential diagnosis in cases of concurrent chylous ascites, pleural effusion and PLE in patients with abdominal pain, fever and weight loss.

A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography.

BACKGROUND: Chylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus. CASE PRESENTATION: A 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites. CONCLUSIONS: Refractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy.

Understanding acute chyloperitoneum in appendicitis: case report and literature review.

Chyloperitoneum is the presence of chyle in the peritoneal cavity. This study focuses on acute chyloperitoneum, a rare condition with an unclear incidence due to limited number of reported cases in the literature. Here, we present a 24-year-old Saudi female with chyloperitoneum diagnosed intraoperatively during a laparoscopic appendectomy for acute appendicitis that was managed successfully with a low-fat diet and drainage, alongside a literature review to elucidate the condition's pathophysiology and therapeutic strategies. A conservative management approach is recommended for acute chyloperitoneum in the context of appendicitis, this includes intraperitoneal drainage, appendectomy when needed, and careful observation. Our proposed management strategy aligns with findings from the literature review and supports conservative management as a safe and effective treatment modality for this rare condition.

Road to recompensation: Baveno VII criteria and transjugular intrahepatic portosystemic shunt in liver cirrhosis.

Liver cirrhosis has long been considered a point of no return, with limited hope for recovery. However, recent advancements, particularly the Baveno VII criteria and the utilization of transjugular intrahepatic portosystemic shunt (TIPS), have illuminated the concept of hepatic recompensation. In this editorial we comment on the article by Gao et al published in the recent issue. This editorial provides a comprehensive overview of the evolution of understanding cirrhosis, the criteria for recompensation, and the efficacy of TIPS in achieving recompensation. We discuss key findings from recent studies, including the promising outcomes observed in patients who achieved recompensation post-TIPS insertion. While further research is needed to validate these findings and elucidate the mech-anisms underlying recompensation, the insights presented here offer renewed hope for patients with decompensated cirrhosis and highlight the potential of TIPS as a therapeutic option in their management.

Case report: Disseminated Cladophialophora bantiana phaeohyphomycosis in a dog with hepatic dysfunction, and concurrent ehrlichiosis.

A 1-year-old mixed breed dog initially presented with marked ascites due to a low-protein transudate resulting from portal hypertension. Laboratory evaluation revealed non-regenerative anemia, lymphopenia, thrombocytopenia, evidence of hepatic insufficiency [hypoalbuminemia, decreased urea, increased post-prandial bile acids, prolonged activated partial thromboplastin time (aPTT)] and Ehrlichia canis infection. Approximately a week later, the dog was declining and was euthanized. On autopsy, multifocal hepatic granulomas and acquired portosystemic shunts (APSS) were seen. Imprint cytology revealed fungal hyphae and pyogranulomatous inflammation in the liver and brain. Disseminated Cladophialophora bantiana phaeohyphomycosis was diagnosed by histologic examination, culture and PCR. Immunosuppression due to ehrlichiosis is suspected to have predisposed this animal to fungal infection. To the authors' knowledge, this is the first report of C. bantiana in the West Indies.

Feasibility and safety study of ultrasound-guided percutaneous microwave ablation for Sub-cardiac liver cancers without artificial ascites assistance.

OBJECTIVES: To investigate the efficacy and safety of ultrasound(US)-guided microwave ablation (MWA) without artificial ascites (AA) inpatients with sub-cardiac liver cancers. MATERIALS AND METHODS: This retrospective study included patients with the left lobe and caudate lobe of the liver cancer who underwent US-guided MWA in our institute from January 2020 to December 2022. According to whether the target lesion was located ≤ 5 mm from the pericardium, patients were divided into the sub-cardiac (SC) group and the non-sub-cardiac (NSC) group. In the SC group, AA was not employed during the ablation procedure. The results of technical success, technical efficiency, local tumor progression (LTP), and major complications were recorded. RESULTS: A total of 79 patients with 87 lesions were enrolled. There were 38 patients with 38 lesions in the SC group and 41 patients with 49 lesions in the NSC group. The median follow-up of all patients was 15 (range, 3-44) months. There was no significant difference in technical success rates (100% versus 100%), technique efficiency rates (100% versus 95.7%), LTP rates (2.63% versus 0%,), and major complication rates (2.63% versus 7.32%) between the SC group and the NSC group (p > 0.05). No cardiac-related complications occurred. CONCLUSIONS: US-guided MWA without AA for sub-cardiac liver cancers was safe and effective. ADVANCES IN KNOWLEDGE: The clinical prognosis of thermal ablation without artificial ascites in the treatment of sub-cardiac liver cancers is still unclear. The finding of this study provided evidence supporting the efficacy and safety of ultrasound-guided microwave ablation without artificial ascites for treating this tricky location.

Colon signet-ring cell carcinoma with chylous ascites caused by immunosuppressants following liver transplantation: A case report.

BACKGROUND: Chylous ascites is caused by disruption of the lymphatic system, which is characterized by the accumulation of a turbid fluid containing high levels of triglycerides within the abdominal cavity. The two most common causes are cirrhosis and tuberculosis, and colon signer ring cell carcinoma (SRCC) due to the use of immunosuppressants is extremely rare in cirrhotic patients after liver transplantation, making it prone to misdiagnosis and missed diagnosis. CASE SUMMARY: A 52-year-old man who underwent liver transplantation and was administered with immunosuppressants for 8 months was admitted with a 3-month history of progressive abdominal distention. Initially, based on lymphoscintigraphy and lymphangiography, lymphatic obstruction was considered, and cystellar chyli decompression with band lysis and external membrane stripping of the lymphatic duct was performed. However, his abdominal distention was persistent without resolution. Abdominal paracentesis revealed allogenic cells in the ascites, and immunohistochemistry analysis revealed adenocarcinoma cells with phenotypic features suggestive of a gastrointestinal origin. Gastrointestinal endoscopy was performed, and biopsy showed atypical signet ring cells in the ileocecal valve. The patient eventually died after a three-month follow-up due to progression of the tumor. CONCLUSION: Colon SRCC, caused by immunosuppressants, is an unusual but un-neglected cause of chylous ascites.

Silent Hemoperitoneum Unveils Advanced Cancer.

A 62-year-old male undergoing peritoneal dialysis (PD) for over two years presented with sudden bloody peritoneal dialysate, but no other symptoms. Laboratory tests indicated anemia, and a computed tomographic scan revealed a 4.4 cm tumor in the liver with hemoperitoneum, leading to a diagnosis of ruptured hepatocellular carcinoma (HCC), stage IIIB T4N0M0. The patient underwent a successful laparoscopic segmentectomy, and PD was resumed after a month of hemodialysis without complications. This case underscores the importance of considering malignancy in PD patients presenting with hemoperitoneum, as timely detection of HCC can significantly improve prognosis.

A case of fungal peritonitis in a patient with paramalignant ascites.

Here, we present the case of a patient with a metastatic neuroendocrine tumor with cytologically negative ascites treated for spontaneous bacterial peritonitis (SBP). Ascitic cultures remained negative for bacterial growth but were positive for Candida albicans 8 days after SBP diagnosis. ß-D-glucan was only positive in ascites, while being negative in blood. Blood cultures remained negative throughout the whole admission. Fungal peritonitis presumably originated from an impending bowl perforation or an increasing vascular permeability caused by an increase in VEGF secondary to diffuse infiltration by the underlying malignant disease.

Impact of Hypoglycemia on Hospitalized Patients With Hepatocellular Carcinoma.

Aims Hepatocellular carcinoma (HCC) is one of the common liver malignancies that presents a challenge to global healthcare. The impact and outcomes of hypoglycemia in HCC have not been studied in detail before. This study aimed to investigate the outcomes and prognosis associated with hypoglycemia in patients diagnosed with HCC, utilizing a large-scale database approach. Methods Using the Nationwide Inpatient Sample (NIS) database from 2017 to 2020, we conducted a comprehensive retrospective analysis to examine the incidence, risk factors, and clinical implications of hypoglycemia on HCC patients. The patients were divided into two groups: those with hypoglycemia and those without hypoglycemia. Univariate and multivariate logistic regression were used to conduct the analysis. STATA® version 17.0 software (StataCorp LLC, College Station, TX) was used for this purpose. Results Out of a total of 343,895 patients with HCC, the prevalence of hypoglycemia was present in 1.5% of this patient population. We found that hypoglycemia was common in the male population (68%). Compared with patients without hypoglycemia, patients who had hypoglycemia with HCC had higher mortality (42%, p-value < 0.05) and higher risks of secondary outcomes such as hepatic failure, spontaneous bacterial peritonitis (SBP), ascites, and portal vein thrombosis compared to patients who did not have hypoglycemia. The multivariate-adjusted odds ratio for hepatic failure was 2.7 (2.3-3.1), for SBP was 2.9 (1.8-3.0), for ascites was 1.6 (1.4-1.9), and for portal vein thrombosis was 1.2 (0.9-1.4). Conclusion In conclusion, hypoglycemia in HCC is associated with increased mortality and worse outcomes.

Pleural effusion, ascites, colon ulcers and hematochezia: What we can learn from the diagnostic process of a patient with plasma cell myeloma: A case report.

BACKGROUND: Plasma cell myeloma (PCM) is characterized by hypercalcemia, renal impairment, anemia, and bone destruction. While pleural effusion, ascites, abdominal pain, and bloody stool are common manifestations of lung disease or gastrointestinal disorders, they are rarely observed in patients with PCM. CASE SUMMARY: A 66-year-old woman presented with complaints of recurrent chest tightness, wheezing, and abdominal bloating accompanied by bloody stools. Computed tomography revealed pleural effusion and ascites. Pleural effusion tests showed inflammation, but the T-cell spot test and carcinoembryonic antigen were negative. Endoscopy showed colonic mucosal edema with ulcer formation and local intestinal lumen stenosis. Echocardiography revealed enlarged atria and reduced left ventricular systolic function. The diagnosis remained unclear. Further testing revealed elevated blood light chain lambda and urine immunoglobulin levels. Blood immunofixation electrophoresis was positive for immunoglobulin G lambda type. Smear cytology of the bone marrow showed a high proportion of plasma cells, accounting for about 4.5%. Histopathological examination of the bone marrow suggested PCM. Flow cytometry showed abnormal plasma cells with strong expression of CD38, CD138, cLambda, CD28, CD200, and CD117. Fluorescence in situ hybridization gene testing of the bone marrow suggested 1q21 gene amplification, but cytogenetic testing showed no clonal abnormalities. Colonic mucosa and bone marrow biopsy tissues were negative for Highman Congo red staining. The patient was finally diagnosed with PCM. CONCLUSION: A diagnosis of PCM should be considered in older patients with pleural effusion, ascites, and multi-organ injury.