A case of volvulus of the intestine with chylous ascites

Ishii Wataru, Sato Norio, Iiduka Ryoji, Ichikawa Tetsuya, Oda Kazumasa, Higaki Satoshi, Kitamura Makoto

doi:10.3893/jjaam.25.233

A 54-year-old man was admitted to our emergency center with persistent abdominal pain that started in the morning. He showed clear consciousness and rebound tenderness was not observed; however, abdominal tenderness was noted around the umbilicus. He had a history of distal gastrectomy for a perforated duodenal ulcer at the age of 26. Plain abdominal X-ray showed a dilatation of small intestine. Contrast-enhanced abdominal CT showed a twisted mesentery (whirl sign), with poor contrast enhancement of some parts of the small intestinal wall. Ascites was also observed. He was consequently diagnosed with a strangulated ileus, and an emergent laparotomy was performed. The laparotomy revealed that the small intestine, 50 to 710 cm on the anal side from the ligament of Treitz, had twisted by 180 degrees, and 360 ml of milky-white ascites was present. The twisted intestine and mesentery were milkywhite. Small bowel resection was not performed because untwisting of the intestinal torsion restored the intestinal blood supply. The ascites triglyceride level was 658 mg/dL, leading to a diagnosis of chylous ascites. The postoperative course was uneventful, and the patient was discharged on the 9th postoperative day. In this case, lymphatic obstruction occurred due to intestinal torsion; however, the intestinal blood flow was not fully interrupted. A CT scan density index of chylous ascites had less than that of hemorrhagic ascites, and if intestine volvulus with chylous ascites can be suspected, laparoscopy may be elected.

A case of volvulus of the intestine with chylous ascites

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