Chylous ascites is the accumulation of triglyceride-rich fluid in abdominal cavity. It is caused by lymphatic ducts injury, usually as consequence of surgery, neoplasia, or infection. Rarely, it can also occur from heart failure, pericarditis, or cirrhosis.
We report the case of a 66-year-old man electively hospitalized for acute renal failure and anasarca state. The cardiological history was significant due to acute myocardial infarction treated with CABG, PM implantation for complete AV block, atrial fibrillation, and type 2 diabetes mellitus. The entero-hepatological history started in 2019 when, two months after abdominal surgery for an incarcerated hernia, he developed chylous ascites and chylotorax. Starting from 2021, the patient presented recurrent episodes of tense ascites, requiring periodic paracentesis. Haematological and infectious disease evaluation resulted negative, liver biopsy showed congestive hepatopathy with fibrosis, while venous catheterization found high right filling pressure with not portal hypertension. Patient was treated with Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Metformin 1500 mg, Enalapril 20 mg, and Simvastatin 20 mg. During the hospitalization other paracentesis confirmed the chylous nature of the effusion, echocardiography (despite very bad acoustic windows) showed preserved left ventricle systolic function (LVEF 55%), 3rd degree LV diastolic disfunction, and dilatation of right ventricle, atria, and inferior Vena Cava. Right heart catheterization confirmed the presence of LV restrictive physiology, combined pulmonary hypertension, and ruled out the diagnosis of constrictive pericarditis. In hospital treatment focused on resolving acute renal failure and hypervolemia through intravenous diuretic and Albumin and on optimizing cardiological therapy. The patient was discharged with the following treatment: Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Canrenone 100 mg b.i.d., Empagliflozin 10 mg, Simvastatin 20 mg, and indication to hypo-lipidic diet.
This case highlights how the coexistence of different predisposing factors of chylous ascites (past abdominal surgery, heart failure and liver disease) can amplify each other. Recognizing the single role of each of them is of pivotal importance to elaborate targeted treatment. Moreover, in literature, there are some cases of chylous ascites associated with constrictive pericarditis and with severe heart failure, but to our knowledge not with coexistence of HFpEF.