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Disruption of the cisterna chyli, as an isolated injury, is a rare event. We report a case.
A 31-year-old window fitter was brought to the accident and emergency department after falling 3 m from a ladder onto an upright fence post, compressing his upper abdomen. He reported sharp pain in the left upper quadrant (LUQ). On examination, he was haemodynamically stable. There were superficial lacerations and tenderness in the LUQ but signs of peritonitis were absent. Urea and electrolytes and amylase were normal, as was the full blood count, apart from a raised white cell count (18.9 × 10L). Erect chest and abdominal X-rays showed nothing abnormal. A CT scan of the abdomen with intravenous contrast showed thickening and streakiness at the root of small-bowel mesentery, with a small amount of free fluid around the liver and in the pelvis. The appearances were suggestive of vascular injury to the small-bowel mesentery. The liver, spleen, kidneys and pancreas were normal and there was evidence of bilateral basal atelectasis (Figure 1a). The patient remained haemodynamically stable and was initially treated conservatively with bed rest, intravenous fluids and analgesia. On the second day, however, he became tachycardic and the LUQ pain and tenderness worsened. A repeat CT scan showed an increase in the thickening and streaking of the small-bowel mesentery anterior to the superior mesenteric vessels. There was no free gas. The appearances were again suggestive of mesenteric vascular disruption (Figure 1b).
At laparoscopy there was fresh blood in the peritoneal cavity and the procedure was therefore converted to a laparotomy. 200 mL of clotted blood was found in the LUQ with no enteric content. There was also a moderate amount of pinkish-white free fluid resembling strawberry milk-shake. The root of the jejunum was completely white and engorged with chyle. A 3 cm linear defect was found in the small-bowel mesentery overlying the superior mesenteric artery along with a 10 cm defect in the mid-ileal mesentery.
There was no major vascular injury. The defects were repaired with 3/0 polydioxanone sutures and a tube drain was left in situ. On the first postoperative day 500 mL of opaque pinkish fluid drained into the bag. The quantity decreased over subsequent days and the drain was removed on the sixth postoperative day. The patient was discharged and recovered well.
Injury to the cisterna chyli will seldom be suspected preoperatively, since the CT appearances are hard to distinguish from vascular injury in the root of the small-bowel mesentery. In this instance the patient responded well to early laparotomy with primary closure. In scientific terms, the weaknesses of this report are the fact that a rupture of the cysterna chyli was not definitively identified and we did not obtain laboratory confirmation that the fluid was chyle. Little has been published on isolated injuries of this sort1,2,3,4. In thoracic duct injuries, however, persistent loss of chyle has serious complications including death5. Therefore prompt intervention is desirable.