The occurrence of isolated (without accompanying chylothorax) chylous ascites after a VATS-esophagectomy is never documented in literature yet. We present a case of a 64-year-old patient who underwent a VATS esophagectomy for carcinoma esophagus and developed such a complication. We usually clip the thoracic duct in mediastinum intraoperatively. Therefore, the leak was unlikely to resolve conservatively as the distal passage of lymph was blocked and the leak site was under constant retrograde pressure. Hence, it was essential to intervene quickly to prevent nutritional deficits in patients by prolonging the conservative trial. We identified the source of the leak at the cisterna chyli through lymphangiography. After evaluating the situation, we decided to embolize the cisterna chyli under interventional radiology (IR) guidance. As the cases reported for cisterna chyli direct embolization are none in literature, this opens newer arenas in interventional radiology for such specific case management.

Chylous ascites (CA) is the accumulation of chylous lymphatic fluid within the abdominal cavity, usually resulting from laceration of the cisterna chyli or one of its major tributaries during retroperitoneal surgery. If left untreated, CA may become life-threatening. Current treatment recommendations favor a stepwise approach, beginning with conservative measures, followed by percutaneous interventions and, in refractory cases, surgical shunting procedures. Conservative management typically consists of dietary restriction of long-chain triglycerides, escalation to total parenteral nutrition (TPN), and adjunctive pharmacotherapy with somatostatin analogues. In most reported cases, these measures result in cessation of chylous leakage within several days. We report a case of CA after robotic-assisted retroperitoneal lymph node dissection (RPLND) in a 35-year-old male with testicular seminoma. Conservative management included paracentesis with drain insertion, TPN, and pharmacotherapy with octreotide. Ascitic fluid analysis confirmed CA with a triglyceride level of 420 mg/dL. Because chylous leakage did not cease after 60 days of hospital-based management, home-based TPN via a central venous port was initiated. Chylous leakage finally resolved after 80 days of conservative treatment. One year later, the patient remained well and had experienced no recurrence of either CA or seminoma. This case demonstrates that conservative treatment of CA may occasionally require a prolonged course and considerable patience from both the patient and the treating team.

Chyloperitoneum is a rare cause of ascites that results from the leakage of lipid-rich lymph into the abdominal cavity. Numerous etiologies can cause chylous ascites, with the most common causes being malignancy, cirrhosis, infection, and post-procedural lymphatic duct injury in adults. We describe a case of delayed chylous ascites formation after a pancreaticoduodenectomy (Whipple) procedure with lymphocele formation and slow leakage into the peritoneal cavity. Prompt recognition and diagnosis are paramount given the high mortality rate, and the management of this condition includes treating the underlying cause, symptom management, nutritional modification, and, in select cases, surgical interventions such as embolization.

The case was a 71-year-old woman who had right renal cell carcinoma with inferior vena cava invasion. After the nephrectomy, chylous ascites appeared. Despite conservative treatment, chylous ascites persisted. No lymphatic leakage was identified on transpedal lymphoscintigraphy, and retrograde thoracic duct cannulation from the left subclavian vein failed. A chylous pseudoaneurysm was identified on computed tomography and embolized percutaneously; however, chylous ascites persisted. Therefore, we performed transhepatic lymphangiography and embolization before placement of a peritoneovenous shunt, and chylous ascites resolved. Transhepatic lymphatic embolization may represent a valuable treatment option for postoperative chylous ascites. This case suggests that hepatoduodenal lymphatic leakage may occur after nephrectomy involving extensive manipulation of the pancreas head or hepatoduodenal ligament, possibly related to cross-communication between hepatoduodenal and mesenteric lymphatics.

Blunt abdominal trauma can be difficult to evaluate, especially when an unusual injury mimics a far more common one. We present a case of a 17-year-old boy who was struck in the abdomen by bicycle handlebars. His initial imaging suggested a possible bladder rupture because of the presence of both intraperitoneal and extraperitoneal fluid. A retrograde CT cystogram, however, ruled out any bladder injury. Because of his worsening condition, he underwent an urgent laparoscopy followed by exploratory laparotomy, which revealed a large volume of milky-white free fluid, suggestive of chyle, within the abdomen. Laboratory analysis of the aspirated fluid showed a high triglyceride level of 1,079 mg/dL, confirming the chylous nature of the fluid. There was an enlarged and engorged cisterna chyli in the retroperitoneum suggesting lymphatic injury. Treatment involved applying fibrin sealant in the region of the cisterna chyli, placing a peritoneal drain, and keeping a diet based on medium-chain triglycerides. The patient recovered well without any recurrence of chylous ascites. This case highlights the need to consider rare lymphatic injuries causing posttraumatic chylous ascites when evaluating blunt abdominal trauma with diffuse abdominal fluid collection, particularly when common injuries have been ruled out but the patient's clinical status continues to worsen.

Chyloascites is the presence of milky peritoneal fluid rich in triglycerides of lymphatic origin. The most common causes include postoperative lymphatic injury, lymphatic or solid neoplasia, and cirrhosis. The occurrence of chyloascites after hysterectomy is very rare. The pathophysiological mechanisms that cause lymph accumulation include obstruction of lymphatic flow due to neoplastic origin or thoracic duct injuries acquired through trauma or surgical procedures. We present the case of a 32-year-old woman with a history of cervical adenocarcinoma, treated surgically, who presented with abdominal distension. The diagnosis was chyloascites, confirmed by paracentesis. She received treatment with octotride with clinical improvement and favorable outcome.

Primary intestinal lymphangiectasia (PIL) is a rare protein-losing enteropathy, typically diagnosed in childhood. Adult-onset PIL is exceptionally rare and poses a significant diagnostic challenge, often diagnosed as other gastrointestinal diseases. A 28-year-old female, presented with recurrent chylous ascites, and hypoalbuminemia (2.3 g/dL); no hepatic dysfunction or immunoglobulin deficiency was evident; comprehensive evaluation excluded hepatic, malignant (lymphoma), and infectious etiologies (tuberculosis, filariasis). Past history is significant for a presumptive diagnosis of Crohn's disease, which was initially made based on clinical picture and laboratory finding of elevated fecal calprotectin, however, endoscopy and histology studies were inconclusive. On further investigations, imaging showed colonic wall thickening with mesenteric lymphadenopathy, and ascitic fluid analysis showed chylous ascites without evidence for malignant or infectious etiology. Upper endoscopy revealed multiple white duodenal plaques, and terminal ileal biopsies confirmed notable lymphatic dilation. Treatment was initiated with dietary modification (low-fat, high-protein, medium-chain triglyceride supplementation) and budesonide; the patient showed partial response. Later on, Octreotide therapy was initiated, and led to gradual resolution of ascites. Adult onset PIL is challenging to diagnose, particularly when initially misdiagnosed as an inflammatory bowel disease. For correct diagnosis, thorough evaluation, by histopathology and exclusion of secondary causes, is essential. Dietary therapy is the mainstay of management; additional benefits can be obtained by pharmacologic options like octreotide in refractory cases. This case is among the first reported cases of adult-onset PIL from Palestine, contributing to the limited literature and highlighting the need for heightened clinical awareness of such rare presentations.

Background and Clinical Significance: Ventriculoperitoneal (VP) shunting remains the standard definitive treatment for progressive neonatal obstructive hydrocephalus. Congenital chylous ascites is an uncommon neonatal condition, most often related to developmental lymphatic abnormalities. The concurrence of hydrocephalus requiring VP diversion with congenital chylous ascites is exceptionally rare and may first become apparent during abdominal access for shunt placement. Awareness of this possibility is clinically important because milky peritoneal fluid at shunt surgery can mimic gastrointestinal injury, and persistent postoperative abdominal fluid collections may be misattributed to shunt-related complications. Case Presentation: A late-preterm female infant (36 weeks' gestation; birth weight 2.3 kg) presented with congenital hydrocephalus. Cranial ultrasonography was consistent with isolated aqueductal stenosis. Preoperative abdominal ultrasonography demonstrated mild ascites. On 27 May 2025, a VP shunt was placed for obstructive hydrocephalus. Upon entering the peritoneal cavity, milky-white fluid was encountered, prompting concern for bowel injury; however, careful exploration showed no gastrointestinal perforation. Ascitic fluid analysis revealed markedly elevated triglycerides (2300 mg/dL), confirming chylous ascites. The VP shunt was completed without an intraoperative complication. During follow-up, the infant showed appropriate growth (weight 3.0 kg; length 50 cm), while ascites persisted, and she was referred for multidisciplinary evaluation and management. Conclusions: This case highlights an exceptionally rare association of congenital chylous ascites with isolated aqueductal stenosis, identified incidentally during VP shunt insertion. Prompt intraoperative recognition, biochemical confirmation, and coordinated follow-up are essential to distinguish congenital chylous ascites from shunt-related abdominal fluid collections and to guide appropriate multidisciplinary care.

Chylous ascites (CA) is a condition characterized by the accumulation of lymphatic fluid in the peritoneal cavity. Although congenital malformations are the most common cause in newborns, infectious agents represent a clinically significant, potentially reversible etiology that benefits from specific therapy. Various pathogens, including bacteria, viruses, fungi, and parasites, can alter the lymphatic system and lead to the leakage of chyle into the peritoneal cavity, resulting in nutritional, immunological, and metabolic deficiencies. We describe the case of a 5-month-old infant presenting with acute abdomen (vomiting, irritability, and abdominal distension) associated with elevated lipase levels. He underwent emergency laparotomy, which revealed chylous ascites in the absence of structural abnormalities. Initial empiric management, centered on the diagnosis of CA, included fasting and total parenteral nutrition (TPN), followed by a gradual dietary transition from a lipid-free milk formula to a formula enriched in medium-chain triglycerides (MCTs) and reduced in long-chain triglycerides, which was well tolerated. Cytomegalovirus (CMV) infection was identified as the underlying cause and confirmed by PCR on blood, urine, ascitic fluid, and gastric biopsies. The etiological diagnosis allowed for specific antiviral therapy, which, combined with nutritional support, led to complete resolution of the case. We also review published cases of infectious CA in children, analyzing the clinical presentation, diagnostic approaches, and therapeutic strategies. Particular attention is paid to nutritional management. Interventions including the use of TPN, fat-free formulas, or MCT-enriched formulas are also important in infectious etiologies for temporarily controlling the chyle loss mechanism while awaiting complete lymphatic restitution. This review emphasizes the importance of recognizing infectious etiologies in chylous ascites and emphasizes the critical role of personalized nutritional support in optimizing recovery.