When appearance is everything: chylous ascites
The present case has been reported in The American Journal of Medicine.

A 75-year-old woman with cirrhosis secondary to nonalcoholic steatohepatitis was admitted with abdominal pain. Her medical history also included coronary artery bypass grafting, congestive heart failure with a reduced ejection fraction of 40%, chronic kidney disease (stage III), type 2 diabetes, and obesity.

Her cirrhosis had been decompensated in the past by paraesophageal varices and refractory ascites. Therapeutic paracentesis was frequently required. One year earlier, the patient's ascites test results demonstrated an elevated serum-ascites albumin gradient of 2.4 g/dL and a borderline total protein level of 2.3 g/dL. At that time, ascites was attributed to portal hypertension from cirrhosis, with a potential contribution from heart failure.

Mild tenderness to abdominal palpation and a positive fluid wave were also noted. In addition, she had 1+ pitting edema of the bilateral lower extremities. The patient's laboratory testing revealed the following levels: serum sodium, 135 mEq/L; creatinine, 1.26 mg/dL (glomerular filtration rate, 41 mL/min); aspartate aminotransferase, 33 U/L; alanine aminotransferase, 9 U/L; alkaline phosphatase, 128 U/L; direct bilirubin, 0.3 mg/dL; total bilirubin, 0.7 mg/dL; albumin, 3.2 g/dL; and total protein, 6 g/dL.

Ultrasound-guided therapeutic paracentesis yielded 3 L of cloudy, amber fluid concerning for possible chylous ascites. The patient experienced immediate relief of her abdominal pain.

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