Spontaneous midgut volvulus causing chylous ascites in an octogenerian

Description

A previously well and independent 85-year-old woman presented to A&E with a 1-day history of sudden onset, cramping lower abdominal pain and vomiting. There were no other symptoms. The patient had a laparoscopic cholecystectomy 20 years ago but no other surgical history. On examination the patient was peripherally shutdown and abdominal examination revealed generalised peritonitis; the patient deteriorated during the course of the clerking, becoming more tachycardic and confused.

CT scanning of the abdomen revealed moderate amounts of free fluid and lymphadenopathy in the small bowel mesentery. Due to the patient's rapid deterioration a laparotomy was performed; the abdomen was found to be full of milky fluid; this was confirmed to be chyle on later biochemical analysis. The small bowel had twisted on its mesentery and looked slightly dusky while being covered in bright white lymphatic infiltrate (figure 1).

Figure 1.

Lymphatic infiltrate in small bowel mesentery.

The volvulus was corrected whereupon the duskiness and white discolouration began to resolve. No further action was required; the patient recovered well and was discharged home 4 days later.

While commoner in children, midgut volvulus causing chylous ascites is rare in adults with only four cases reported in the literature.^{1 2} This case illustrates how volvulus may occur at any age; it mimics any condition causing peritonitis with free fluid, and is unlikely to be considered as a diagnosis prior to laparotomy. It can cause severe rapid deterioration but is easily correctible with prompt surgery.

Learning points

• Midgut volvulus can occur in patients of any age and is easily correctible with surgery.

• Chylous ascites is an unusual cause of peritonitis and free fluid, mimicking many other conditions.

• In a rapidly deteriorating patient with peritonitis the patient should have an urgent laparotomy.