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.

We present a rare case of severe lymphatic leakage resembling hypovolemic shock following retroperitoneal lymphadenectomy for endometrial cancer. A 62-year-old female developed massive lymphorrhea and chylous ascites following total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. Immediately postoperatively, massive lymphatic leakage caused hypotension and oliguria necessitating vasopressor support. Conservative management, including fasting and octreotide, was unsuccessful. Lymphangiography with Lipiodol and subsequent embolization using N-butyl cyanoacrylate were performed but did not achieve hemodynamic stabilization. Re-laparotomy was undertaken, and indocyanine green injection into the bilateral inguinal lymph nodes, along with oral milk ingestion, enabled precise intraoperative identification of leakage sites. These were successfully ligated with adjunctive fibrin glue and oxidized cellulose. Hemodynamics rapidly improved following repair. Although most lymphatic leakages resolve conservatively, severe cases can cause life-threatening circulatory failure. This case highlights the importance of a multidisciplinary approach, including interventional radiology and surgical repair, to achieve successful outcomes.

Chylothorax, the accumulation of lymphatic fluid within the pleural cavity, results from disruption or obstruction of the thoracic duct or its tributaries, or from transdiaphragmatic chylous ascites. When severe, this condition may impair respiratory function and induce metabolic complications because of chronic loss of protein and lipids. Management strategies ranging from dietary modifications, medical therapy, surgical ligation, pleurodesis, and lymphatic embolization, generally follow a tiered approach. Special considerations apply to chylothorax associated with central venous obstruction or concurrent chylous ascites, sometimes requiring unique management strategies. The various approaches to the management of chylothorax and their appropriateness in a variety of clinical circumstances are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Chylous lymphocyst or lymphocele following pelvic and para-aortic lymphadenectomy is rare. Clinically, patients usually present with abdominal distension or abdominal pain. The milky appearance of the cystic fluid reflects its high triglyceride content. Although specific guidelines for managing chylous lymphocyst are limited, the approaches used for chylous ascites can generally be applied. More than 70% of patients respond to conservative treatment, which includes a modified diet consisting of high protein, fat restriction, and medium-chain triglyceride supplementation. We present the case of a 45-year-old woman who developed a symptomatic 15-cm pelvic lymphocyst one month after surgical staging for a mucinous borderline ovarian tumor. Following the placement of a percutaneous catheter drainage (PCD), the initial output was 300-400 mL/day of clear serous fluid. Notably, a delayed chylous conversion occurred on the 20th day of drainage, the fluid turned milky and biochemical analysis confirmed a triglyceride level of 493 mg/dL. Initiation of a modified high-protein, fat-restricted diet resulted in a rapid decrease in drainage volume to 30 mL/day within 24 hours, alongside a return to clear yellowish appearance. This study aims to report the clinical manifestations and to summarize current therapeutic options for patients with chylous leakage.

A cerebral ethiodized oil embolism is a rare and serious complication of lymphangiography. We herein report a case of a cerebral ethiodized oil embolism after lymphangiography. The patient underwent ultrasound-guided intranodal lymphangiography for refractory chylothorax and chylous ascites due to hilar cholangiocarcinoma. After the procedure, the patient developed a disturbance of consciousness and convulsions. Diffuse embolisms of ethiodized oil micro-droplets in the bilateral cerebral cortex, basal ganglia, thalamus, and cerebellum were detected using brain computed tomography and magnetic resonance imaging. The onset of a cerebral ethiodized oil embolism should therefore be considered when patients present with neurological symptoms, such as consciousness disturbance after lymphangiography.