Refractory Chylous Ascites with Chylothorax and an Umbilical Hernia in a Patient Ineligible for a Transjugular Intrahepatic Portosystemic Shunt

BACKGROUND Chylous ascites is a rare condition, which is defined by accumulation of a milky fluid due to high triglyceride levels. It is most commonly secondary to malignancy, liver cirrhosis, infection, and tuberculosis. CASE REPORT A 21-year-old woman from rural Indonesia, came to the hospital with chronic dyspnea and a history of repeated paracentesis. Six years ago, she was diagnosed with chronic hepatitis B. For the past 2 years, she had complaints of progressive dyspnea and increased abdominal swelling. On examination, there was dullness on chest percussion and decreased breath sounds. Shifting dullness was positive on abdominal examination. Paracentesis and thoracentesis were performed and showed high triglyceride levels. She underwent an abdominal computed tomography scan and was diagnosed with liver cirrhosis, complicated with chylous ascites and chylothorax. Repeated paracentesis was performed as a therapeutic approach; she had strict diet guidelines, and was prescribed octreotide, furosemide, spironolactone, and albumin. Despite this treatment, two years later, she developed an umbilical hernia complicated with ulceration. Hernia repair was not possible due to her comorbidities. She was indicated for a transjugular intrahepatic portosystemic shunt (TIPS) for the refractory chylous ascites. However, this could not be performed as the patient could not afford this expensive procedure, which was not covered by insurance. CONCLUSIONS Management of refractory chylous ascites is challenging, especially in underdeveloped countries due to socioeconomic problems and limited health care facilities. Although TIPS is indicated in refractory chylous ascites, repeated paracentesis can be useful as an alternative method.