We report the case of a 35-year-old patient.
She was referred to our unit after her third hospitalization in the previous 18 months due to recurrent chylous ascites.
With no history of interest, she was admitted for the first time with ascites and mild edema in the lower limbs of a month and a half of evolution, performing exploratory laparotomy in the suspicion of ovarian neoplasia.
Twelve ascitic fluid stools with chylous characteristics were evacuated, without showing ovarian anomalies or peritoneal carcinomatosis.
The patient was discharged on diuretic treatment with isoniazid 100 mg and prednisone 40 mg. At 5 months, she was discharged on an outpatient basis for chylose fluid challenge after discharge.
At a new admission, 6 months later, during which the symptomatology reappeared progressively, the patient recovered 14 more peritoneal fluid.
During his hospitalization, the following complementary tests were performed: blood count, with discrete leukocytosis and normal formula, iron study without alterations; biochemical profile, with hypoproteinemia and hypoalbuminemia, hypocalcemia.
Determinations of celiac profile, HBsAg, HCVAb, tumor markers, and Mantoux were negative.
ASLO levels, C-reactive protein and serum a-1 antitrypsin were normal.
Normal thyroid function study.
Serum proteinogram showed lower albumin and gammaglobulin values.
The extracted ascitic fluid presented exudate and chylous aspect.
Culture was negative.
A CAT scan revealed normal chest, ascites in all peritoneal compartments, and edema in the small intestine loops.
Abdominal ultrasound showed abundant peritoneal ascitic fluid, with normal liver, portal, great vessels, gallbladder and spleen.
Fibroenteroscopy, reaching blind, shows irregularity in the villous pattern, edema of the folds and numerous punctiform lymphangiectasias ranging from bulbo-enteroscopic examination.
Ileoscopy was performed, showing the terminal ileum an extremely irregular mucosa with whitish and friable plaques on biopsy.
Capsulendoscopic examination shows diffuse involvement of the small intestine, with punctiform formations "in mud grain" and edematous and congestive folds.
Biopsy of the intestinal mucosa was reported as lymphoid follicular hyperplasia, focal lymphangiectasia, and gastric, duodenal and jejunal mucosa did not show significant alterations.
Treatment with diuretics and intravenous albumin was initiated, presenting a favorable clinical evolution. The patient was discharged with the diagnosis of primary intestinal lymphangiectasia. Home treatment with Furosemide was given Dietnis 30 mg, and the patient was referred with Nutrition Pred.
Examination in the consulting room showed a height of 1.65 m, weight 53.5 kg, with BMI 19.3 kg/m2, after evacuation of 14 L of ascitic fluid during admission, subjectively before the onset is thinner than before.
Cutaneous stricture, fingertips, mild, manometric edema.
The rest of the physical examination is normal.
She reported no usual gastrointestinal symptoms, except for 1-2 stools a day with a somewhat fat appearance.
It performs a varied diet, avoiding excessively fatty foods forever due to intolerance.
He denies toxic habits.
Nuligesta.
Analytically, he had serum total protein values 3.4 g/dL, albumin 2.1 g/dL, calcium 7.3 mg/dL.
The rest of basic biochemistry, lipid profile, and blood count were normal.
We decided to initiate dietary treatment.
A customized diet of 2,200 kcal is made in 24 hours and the following nutrient distribution: 52% carbohydrates, 30% lipids, 18% protein.
The contribution of fats from foods is restricted, and lipids are provided in the form of MCT oil, using the amount of 85 ml per day, introduced in the diet progressively to avoid intolerances.
Protein contributions from the diet are completed with 400 ml of hyperproteic formula for enteral nutrition and 20 g of protein module powder.
Additionally, mineral-technical complement is added.
The patient is a collaborator and has a strict compliance with the recommended guidelines, with good adaptation and excellent tolerance.
After 11 months of follow-up, he achieved gains with a weight of 59.3 kg and BMI 21.4.
Analytical parameters showed a significant improvement, with serum total protein values 5.2 g/L, albumin g/L, calcium 8.5 mg/dL.
There are no gastrointestinal symptoms.
Waist circumference was 78 cm, and abdominal ultrasound showed no free fluid in the abdomen.
She had no new episodes of ascites and did not require hospitalization during this period.
