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“Milky” bowel and malrotation
ARTICLE IN PRESS
“Milky” bowel and malrotation Gabriele Poillucci, MD,a Ferruccio Degrassi, MD,b Edoardo Guida, MD,c and Federica Pederiva, MD, PhD,c Trieste, Italy
From the Department of Radiology,a University Hospital of Trieste; and the Departments of Radiologyb and Pediatric Surgery,c Institute for Maternal and Child Health, IRCCS “Burlo Garofolo,” Trieste, Italy
A 28-DAY-OLD BOY was referred to our hospital with 2day history of nonbilious vomiting and loss of appetite. He was breast fed and tolerating his feeds
massive ascites was noted. An urgent upper gastrointestinal contrast study demonstrated a dilated duodenum with a “corkscrew” appearance and
Fig. (A) Mesenteric lymphatic obstruction at the cecum. (B) The chylous lymphatics within the cecum dissipated after performing a Ladd’s procedure. (Color version of this figure is available online.)
well prior to his presentation. He was apyrexial. Urine output and stools were normal. On examination, his vital signs were within range. The abdomen was mildly distended but soft. Blood tests were normal. Abdominal x-ray showed an air-fluid level in the stomach and a paucity of gas in the rest of the intestine. On abdominal ultrasound, a
The authors declare no financial assistance or any potential conflict of interest, real or perceived. Accepted for publication August 11, 2016. Reprint requests: Gabriele Poillucci, MD, University Hospital of Trieste, Strada di Fiume 447, Trieste 34137, Italy. E-mail: [email protected]. Surgery 2016;j:j-j. 0039-6060/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.08.010
the duodenojejunal flexure to the right of the midline, in keeping with malrotation. The patient was taken for a laparotomy. Together with chylous ascites, a mesenteric lymphatic obstruction (Fig, A) associated with intestinal malrotation without volvulus was found. Upon performing a Ladd’s procedure, the chylous lymphatics within the cecum dissipated (Fig, B). An inversion appendectomy was also performed. No reaccumulation of ascites was seen, and the patient was discharged home on full enteral feeds after 5 days. Few case reports in the literature describe the association of chylous ascites and malrotation,1-4 likely due to volvulus or, in its absence, to the weight of the bowel loops, which increases the lymphatic pressure and contributes to the leakage of chyle into the peritoneum. Once the volvulus is treated operatively or the adhesions are divided, the chylous ascites resolves. SURGERY 1
ARTICLE IN PRESS 2 Poillucci et al
Pediatricians should consider the need of a workup for malrotation in an infant with ascites not explained by other causes. REFERENCES 1. Zarroug AE, Srinivasan SK, Wulkan ML. Incidental chylous fluid during hernia repair may be a harbinger of malrotation. J Pediatr Surg 2010;45:E17-8.
Surgery j 2016
2. Vasko JS, Tapper RI. The surgical significance of chylous ascites. Arch Surg 1967;95:355-68. 3. Shariff FU, Curry J, De Coppi P, Drake DP. Laparoscopic finding of chylous ascites and intestinal malrotation in an infant presenting with left inguinal hernia. J Laparoendosc Adv Surg Tech A 2008;18:651-3. 4. Seltz LB, Kanani R, Zamakhshary M, Chiu PP. A newborn with chylous ascites caused by intestinal malrotation associated with heterotaxia syndrome. Pediatr Surg Int 2008;24: 633-6.
“Milky” bowel and malrotation Gabriele Poillucci, MD,a Ferruccio Degrassi, MD,b Edoardo Guida, MD,c and Federica Pederiva, MD, PhD,c Trieste, Italy
From the Department of Radiology,a University Hospital of Trieste; and the Departments of Radiologyb and Pediatric Surgery,c Institute for Maternal and Child Health, IRCCS “Burlo Garofolo,” Trieste, Italy
A 28-DAY-OLD BOY was referred to our hospital with 2day history of nonbilious vomiting and loss of appetite. He was breast fed and tolerating his feeds
massive ascites was noted. An urgent upper gastrointestinal contrast study demonstrated a dilated duodenum with a “corkscrew” appearance and
Fig. (A) Mesenteric lymphatic obstruction at the cecum. (B) The chylous lymphatics within the cecum dissipated after performing a Ladd’s procedure. (Color version of this figure is available online.)
well prior to his presentation. He was apyrexial. Urine output and stools were normal. On examination, his vital signs were within range. The abdomen was mildly distended but soft. Blood tests were normal. Abdominal x-ray showed an air-fluid level in the stomach and a paucity of gas in the rest of the intestine. On abdominal ultrasound, a
The authors declare no financial assistance or any potential conflict of interest, real or perceived. Accepted for publication August 11, 2016. Reprint requests: Gabriele Poillucci, MD, University Hospital of Trieste, Strada di Fiume 447, Trieste 34137, Italy. E-mail: [email protected]. Surgery 2016;j:j-j. 0039-6060/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.08.010
the duodenojejunal flexure to the right of the midline, in keeping with malrotation. The patient was taken for a laparotomy. Together with chylous ascites, a mesenteric lymphatic obstruction (Fig, A) associated with intestinal malrotation without volvulus was found. Upon performing a Ladd’s procedure, the chylous lymphatics within the cecum dissipated (Fig, B). An inversion appendectomy was also performed. No reaccumulation of ascites was seen, and the patient was discharged home on full enteral feeds after 5 days. Few case reports in the literature describe the association of chylous ascites and malrotation,1-4 likely due to volvulus or, in its absence, to the weight of the bowel loops, which increases the lymphatic pressure and contributes to the leakage of chyle into the peritoneum. Once the volvulus is treated operatively or the adhesions are divided, the chylous ascites resolves. SURGERY 1
ARTICLE IN PRESS 2 Poillucci et al
Pediatricians should consider the need of a workup for malrotation in an infant with ascites not explained by other causes. REFERENCES 1. Zarroug AE, Srinivasan SK, Wulkan ML. Incidental chylous fluid during hernia repair may be a harbinger of malrotation. J Pediatr Surg 2010;45:E17-8.
Surgery j 2016
2. Vasko JS, Tapper RI. The surgical significance of chylous ascites. Arch Surg 1967;95:355-68. 3. Shariff FU, Curry J, De Coppi P, Drake DP. Laparoscopic finding of chylous ascites and intestinal malrotation in an infant presenting with left inguinal hernia. J Laparoendosc Adv Surg Tech A 2008;18:651-3. 4. Seltz LB, Kanani R, Zamakhshary M, Chiu PP. A newborn with chylous ascites caused by intestinal malrotation associated with heterotaxia syndrome. Pediatr Surg Int 2008;24: 633-6.