SHM Converge Scientific Abstract ePoster Gallery-When It Quacks Like a Duct: A Case of Ascites

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A 54-year-old woman presented with six months of diarrhea and weight loss, followed by three months of abdominal distension. Exam showed diffuse abdominal distension and tenderness. Workup revealed low albumin, large ascites, normal liver tests, and no evidence of cirrhosis, heart failure, nephrotic syndrome, ovarian mass, or malignancy. Ascitic fluid had a low SAAG, normal triglycerides, and negative cytology. Additional findings included nutritional deficiencies, elevated fecal fat, and a positive stool alpha-1 antitrypsin, supporting protein-losing enteropathy (PLE).<br /><br />Because common GI, hepatic, cardiac, renal, infectious, and autoimmune causes were excluded, the team pursued evaluation for lymphatic obstruction. Endoscopy did not identify a cause. MR lymphangiogram showed sluggish thoracic duct flow, suggesting thoracic duct obstruction. She underwent thoracic duct angioplasty with temporary improvement in symptoms, but diarrhea recurred. A repeat angioplasty again produced only transient benefit. Ultimately, she underwent thoracic duct bypass to the external jugular vein, after which her diarrhea fully resolved, albumin normalized, and she returned to baseline weight.<br /><br />This case highlights that when standard causes of ascites are excluded, PLE due to thoracic duct pathology should be considered. Thoracic duct obstruction is a rare but important cause of lymphatic leakage and intestinal protein loss. Lymphangiography can help define the diagnosis and guide intervention. In refractory cases, thoracic duct bypass may provide durable symptom resolution.

Asset Subtitle

Lara J. Sokoloff

Meta Tag

Author List Lara J. Sokoloff, Maxim Itkin, Megan Asher, Stephen J. Kovach, Todd E. Hecht

Category Clinical Vignettes

Concept Protein-Losing Enteropathy

Concept Low Serum-Ascites Albumin Gradient

Concept Thoracic Duct Obstruction

Concept Hypoalbuminemia

Concept Stool Alpha-1 Antitrypsin

Distinguished Non-Finalist

Presenter Organization Hospital of the University of Pennsylvania

Presenting Author Lara J. Sokoloff

Track Adult

Keywords

protein-losing enteropathy

thoracic duct obstruction

ascites

diarrhea

weight loss

lymphatic obstruction

MR lymphangiogram

thoracic duct angioplasty

thoracic duct bypass

low SAAG

Protein-Losing Enteropathy

Low Serum-Ascites Albumin Gradient

Thoracic Duct Obstruction

Hypoalbuminemia

Stool Alpha-1 Antitrypsin