CASE REPORT |
https://doi.org/10.5005/jp-journals-11006-0153 |
Hyperextension Injury of Spine Causing Cisterna Chyli Injury: A Rare Case Report of Traumatic Chylous Ascites
1–4Department of Critical Care Medicine, Gopala Gowda Shanthaveri Memorial Hospital, Mysuru, Karnataka, India
Corresponding Author: Aishwarya Sadashivamurthy, Department of Critical Care Medicine, Gopala Gowda Shanthaveri Memorial Hospital, Mysuru, Karnataka, India, Phone: +91 8105634115, e-mail: aishwarya.ssm@gmail.com
Received: 29 November 2024; Accepted: 22 December 2024; Published on: 25 February 2025
ABSTRACT
Aim and background: Chylothorax and chylous ascites (CA) are often seen after postoperative damage to the thoracic duct, specifically at the cisterna chyli. However, there are rare traumatic causes of the same. This makes it grueling to diagnose and treat. In the present case, we noticed the abovementioned complication after a hyperextension injury of the spine. We believe that shearing forces have a role to play in this scenario. Nonetheless, timely management of such patients can prevent severe morbidity and untimely mortality.
Case description: A 40-year-old male presented with a history of a fall and was diagnosed with a hyperextension injury of the spine. He underwent a magnetic resonance imaging (MRI) of the spine to confirm the same. His injuries were managed conservatively, and he was discharged. One month later, he presented with progressive abdominal distension and dyspnea, which revealed an unusual diagnosis of CA. Laparotomy confirmed the source of the leak from the cisterna chyli.
Conclusion: CA is a rare complication of hyperextension injury of the spine. When ascites or pleural effusion is noted persistently, injury to the thoracic duct or cisterna chyli must be suspected.
Keywords: Rare case report, Shearing forces, Thoracic duct, Traumatic chyle leak
How to cite this article: Sadashivamurthy A, Sannakki LB, Aladakatti R, et al. Hyperextension Injury of Spine Causing Cisterna Chyli Injury: A Rare Case Report of Traumatic Chylous Ascites. Indian J Crit Care Case Rep 2025;4(2):41–43.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
INTRODUCTION
Chylothorax is the condition in which lymphatic fluid is present in the pleural space. Injury to the cisterna chyli is uncommon, especially as a result of trauma. Chylous ascites (CA) is the collection of a milky white peritoneal fluid abundant in triglycerides, accumulated in the abdominal cavity when there is a discontinuity of the lymphatic system due to traumatic injury or obstruction. It is an atypical finding with a reported incidence of around 1 in 20,000 admissions at a university-based hospital over a 20-year time span in a study. Blunt abdominal trauma causing intestinal injury with or without associated mesenteric injury is the most common mechanism of trauma.
Asellius first described lymphatics in a dog after observing milky white fluid in the mesenteric vessels. Later, in the 17th century, Morton noted CA in a case of disseminated tuberculosis in an 18-month-old child. The most common causes in adults in postindustrial countries are abdominal carcinoma and cirrhosis. In low- and middle-income countries, infectious causes—tuberculosis and filariasis—are seen. Other causes include healthcare-related issues during surgical procedures and blunt abdominal trauma. Causes of chylothorax could be traumatic or nontraumatic. Commonly, nontraumatic chylothorax can either be due to undiagnosed malignancy, infection, or inflammation. Traumatic chylothorax occurs due to injury to the thoracic duct either via penetrating trauma or postoperative/iatrogenic complication.
This is an uncommon occurrence that, based on our information, is reported infrequently in the literature. The aim of this case report is to discuss the management of the unusual clinical presentation of CA and chylothorax attributable to hyperextension injury of the thoracolumbar spine.
CASE DESCRIPTION
A 40-year-old male patient, from a rural area, presented to the emergency department with an alleged history of a fall on the edge of a truck while trying to hold on to his cow, suffering hyperextension of the spine. The patient sustained injury to his chest and lower back. On arrival, he was conscious and oriented, complaining of difficulty breathing, weakness of both lower limbs, and severe lower back ache.
The patient was received on a spine board with a cervical collar in place. On examination, the patient was tachycardic and tachypneic with stable blood pressure and 99% saturation on room air. Paraplegia was noted, with power of both upper limbs and lower limbs being 0/5. On abdominal examination, there were no external injuries, but lower abdominal tenderness was present.
After intensive care unit (ICU) admission, computed tomography images showed a D9-D12 spinous process fracture with a D10-D11 cord contusion, mild hemoperitoneum, and multiple rib fractures on the right side with pneumothorax, which was managed conservatively. Once the patient improved, he was shifted to the ward. On day 11, weakness of the limbs improved (power 2/5), and he was discharged.
One month later, the patient developed breathlessness with distension of the abdomen and swelling of both lower limbs, and had not passed stools or flatus for 3 days. Paraparesis persisted. The patient was admitted to the intensive care unit. Bedside ultrasound showed gross ascites with bilateral pleural effusion (right > left). Computed tomography (CT) abdomen contrast study showed no intestinal abnormalities but revealed gross ascites with central displacement of bowel loops. A surgical gastroenterology consultation was sought. On day 3 of admission, ultrasound-guided percutaneous drainage of ascitic fluid was done, draining around 1000 mL of chylous fluid, for which a pigtail was inserted. Fluid analysis revealed a triglyceride level of 391 mg/dL. The patient was symptomatically better after drainage. Despite adequate drainage, a continuous drain of around 330 mL per day was noted from the abdomen, for which surgical intervention was performed. Intraoperatively, there was evidence of injury to the cisterna chyli, which was ligated during laparotomy. The postoperative period was uneventful.
The patient is now on regular follow-up and has symptomatically improved. In repeat imaging, the recollection of fluid is not significant, so the patient is maintained on a fat-free diet (Figs 1234).
Fig. 1: Chylous pleural fluid drained after the hyperextension injury of the spine
Fig. 2: MRI of spine sagittal sections showing hyperextension injury
Fig. 3: Intraoperatively, milky fluid noted in the retroperitoneum
Fig. 4: Management protocol for CA
DISCUSSION
The receptaculum chyli (as first described by Jean Pecquet) is an important anatomical structure that drains lymphatic fluid from the abdominal organs, right and left lumbar lymphatic trunks (which drain lymph from the lower limbs, kidneys, adrenal glands, and the abdominal wall), and small lymph vessels from the lower thorax. While it is uncommon, it can be injured via shearing forces in blunt trauma or, rarely, via penetrating injuries.1
Noninvasive CT abdomen and pelvis is the investigation of choice, as it helps in early diagnosis by identifying pathological intra-abdominal lymph nodes and masses, which aids in determining the extent and localization of fluid.2
Abdominal paracentesis aids in both diagnostic interpretation and treatment planning. The typical appearance of the milk-like ascitic fluid, which is cloudy and turbid with triglyceride levels typically above 200 mg/dL, is seen, as observed in our case.
Lymphangiography is another imaging modality to evaluate chyloperitoneum and chylothorax. This also helps detect abnormal retroperitoneal lymph nodes, leakage or dilation of lymphatic channels, fistula formation, skip metastasis, and free flow of the thoracic duct. Additionally, lymphoscintigraphy can also be performed.3
The treatment starts with diet to reduce the enterolymphatic flow by adjusting the components of enteric intake. The patient is kept NPO, and initiation of a low-fat, high-protein diet is the starting point of therapy with restriction of long-chain triglycerides. Total parenteral nutrition (TPN) is another modality, involving intravenous delivery of nutritional products in patients who are unable to tolerate enteral feeding. It allows the bowel to rest and decreases the production and flow of lymph.1,3
Somatostatin (3 mg over 12 hours intravenous flow) acts to suppress splanchnic intestinal peptides like glucagon, which decreases portal pressure and enterohepatic lymphatic flow, reducing chyle leakage. It also decreases intestinal secretions, inhibiting intestinal motility.4
Octreotide, a synthetic analog of somatostatin with a longer half-life, can be used as subcutaneous administration with an initial dose of 100 µg three times daily. Diuretics can be used, as discussed in studies, to improve peripheral edema as a consequence of hypoalbuminemia.4
If ascites is resistant to conservative management or refractory to medical management for 2 weeks, surgical exploration should be planned. In both traumatic and postoperative cases of CA, when surgery is indicated, there is a need for systematic exploration to rule out any other concomitant injuries of the intra-abdominal structures.5,6
The surgical approach is through laparotomy and exploration or a laparoscopic approach. Ligation with nonabsorbable sutures is the most extensively used and established method. In our patient, an open method was preferred.
Identifying the site of leakage is crucial, with agents such as methylene blue or enteral regimens prior to surgery described, including Intralipid, milk, dyed or colored cream, and peanut oil. A widely used plan is the administration of around 200 mL of the agent 6 hours prior to exploration or intraoperatively, through a nasogastric tube.5
Newer techniques such as percutaneous embolization with lymphangiography, with or without embolization, are used in patients with failed medical management. The closest lymph node is embolized with agents such as butyl cyanoacrylate and doxycycline. Another technique described is the use of etilefrine, which contracts the smooth muscle of the thoracic conduit and decreases the inflow of chyle. However, these methods are still under development.6
CONCLUSION
Chylous ascites is a rare complication of hyperextension injury of the spine. When ascites or pleural effusion are noted persistently, injury to the thoracic duct or cisterna chyli must be suspected.
ORCID
Aishwarya Sadashivamurthy https://orcid.org/0000-0003-3436-1827
Laxmikant B Sannakki https://orcid.org/0009-0000-8813-4983
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