Enteroscopy as a diagnostic modality in the diagnosis of chylous ascites

Chylous ascites is an uncommon cause of ascites and its etiology could be a diagnostic challenge. We present one such case of chylous ascites that was diagnosed in a 44 year-old African-American woman who presented with new onset of ascites and abdominal pain. Physical examination was remarkable for generalized lymphadenopathy and a 8 cm periumblical mass lesion. There was no hepatosplenomegaly. Laboratory data was significant for a normocytic anemia (Hb=8.5) and leucocytosis with a left shift and thrombocytosisD Abnormalities on liver function test were a total protein 4.1, albumin 1.9, cholesterol 128, Alk Phos 371 and GGT 185. Ascitic fluid analysis showed a low SAAG ascites (0.9), TG 341 with WBC count of 610 (L: 73%, N: 5%). Cytology of the fluid was non conclusive. CT abdomen showed large ascites and bulky retroperitoneal lymphadenopathy. With a clinical suspicion of malignancy/lymphoma, an axillary lymph node biopsy was planned for tissue diagnosis, which was inconclusive even after flow cytometry. Hence an open laparotomy was performed. It showed a large 8 cm 10 cm mesenteric mass in the jejunal area, with extension to the mesenteric vessels and periaortic area. Frozen section and biopsy were negative for malignancy. At this point an enteroscopy was performed, which showed diffuse erythematous mucosa with multiple small nodules in the third portion of the duodenum and jejunum. Histopathology of biopsy specimens revealed an atypical large cell malignant lymphoma. Chylous ascites is most commonly caused by cirrhosis and malignancy/ lymphoma. GI tract is the most frequent location for primary extranodal lymphomas. Various modalities can be used in making the diagnosis of the underlying cause. Our case is an example where enteroscopy as an adjunctive test was able to identify the cause of chylous ascites despite inconclusive findings on more invasive interventions.