chylous ascites is an accumulation of milky lipid - rich lymph in the peritoneal cavity caused by a disruption in the lymphatic system . it was first identified in 1694 by richard morton in a 2-year - old male who died with tuberculosis . chylous ascites is fairly rare in the clinical setting , with a reported incidence of approximately 1 in 20 000 presenting to the hospital [ 13 ] . left untreated , it can lead to nutritional deficiency and in some cases immunosuppression . in rare cases , patients presenting emergently with volvulus or appendicitis have incidentally been found to have chylous ascites upon surgical exploration [ 24 ] . paraesophageal hernia can present acutely with gastric obstruction or strangulation at an estimated incidence of 1.2% per patient per year , the treatment for which involves laparoscopic or open hernia reduction , resection of the hernia sac , repair of the hiatal defect and fundoplication . we report the unique observation of spontaneous chylous ascites , chylothoraces and chylomediastinum occurring in the setting of an incarcerated paraesophageal hernia . a 60-year - old female with a long - standing gastroesophageal reflux disease and known type iii paraesophageal hernia presented to the emergency department with acute epigastric pain , dysphagia and vomiting . she noted a 1-month history of progressive dysphagia as well . computed tomography ( ct ) revealed a large paraesophageal hernia with significant surrounding fluid concerning for incarceration ( figs  1 and 2 ) . owing to these findings and her discomfort , emergent laparoscopic repair of her paraesophageal hernia was recommended . figure  1:axial ct view of the paraesophageal hernia and mediastinal fluid . 
 figure  2:coronal ct view of the paraesophageal hernia and mediastinal fluid . access to the peritoneal cavity began with a 2-cm incision at the umbilicus using the hasson technique . after insufflation , four 5-mm trocars were introduced to the left and right upper quadrants . chylous fluid was immediately visualized in the vicinity of the greater curvature of the stomach with the preponderance of the fluid at the splenic hilum and splenic flexure . upon entering the lesser sac , chyle was found covering the pancreas as well . at this point , 20 ml of this chylous fluid was aspirated and sent for fluid analysis . the report later returned with triglyceride levels of 3362 mg / dl , consistent with chyle . during the hernia sac dissection , two 19-fr blake drains were placed : one in the lesser sac extending to the splenic flexure and one in the mediastinum . chest tubes drained about 100 ml of chylous fluid each , after which the output transitioned to serous . an abdominal and pelvic ct scan revealed no signs of malignancy that may have caused the chyle leak . the etiologies for chylous ascites can be categorized as traumatic or atraumatic , with malignancy and cirrhosis comprising the majority of atraumatic causes in the developed world via disruption of lymphatic flow . spontaneous chylothoraces due to compression of the thoracic duct by a large substernal goiter and thoracic aorta aneurysm have been reported in the literature as well [ 6 , 7 ] . because the chyle leak resolved rapidly after reduction of the hiatal hernia in this case , it could be postulated that acute incarceration of the hernia within the chest led to significant inflammation and subsequent compression of the thoracic duct above the hiatus . the chyle found within the abdomen could be explained as a transudate from the chest , where the initial disruption to the lymphatic system likely occurred . the most common presenting symptom for isolated chylous ascites is painless abdominal distention , but a subset of patients may present with peritoneal irritation or unspecified abdominal pain . whether chylous ascites is suspected in a clinical setting or incidentally in the operative room , analyzing fluid to confirm diagnosis is critical . for this reason , abdominal paracentesis may be indicated when suspicion for ascites exists at the time of presentation . chyle is classically defined as turbid and milky in character with triglyceride levels above 200 mg / dl [ 1 , 8 ] . in our patient , analysis of the fluid encountered during laparoscopy showed triglyceride levels of 3362 mg / dl , well above the diagnostic marker . imaging studies , such as ct , lymphoscintigraphy and lymphangiography , also have roles in diagnosing chylous ascites preoperatively . the most important initial step is treatment of the underlying cause of the chyle leak [ 3 , 9 ] . in this case , reduction of the paraesophageal hernia was imperative to relieve potential compression of the thoracic duct as well as to treat the incarcerated hernia . medical management is typically aimed at improving nutritional status and decreasing chyle flow , thereby allowing spontaneous closure of the chyle leak . a high - protein and a low - fat diet with middle - chain fatty acids has proved successful . numerous case reports have endorsed pharmacotherapy such as octreotide and somatostatin either alone or in combination with total parenteral nutrition in managing a refractory chyle leak [ 1 , 2 , 9 ] . in cases of chylothorax , pleuro - peritoneal shunts or chest tubes are found to be useful , especially if severe dyspnea is present . although there currently lacks a universal approach to treating chylous leakage , surgical reduction of the hernia and dietary restriction were successful in our atypical case .
chylous ascites is an accumulation of milky lipid - rich lymph in the peritoneal cavity . 
 spontaneous chyle leak is a rare occurrence , often associated with malignancy or cirrhosis . 
 this is a report of spontaneous chylous ascites , chylomediastinum and chylothoraces encountered in the setting of an incarcerated paraesophageal hernia . 
 a 60-year - old female presented to the emergency department with epigastric pain , dysphagia and vomiting . clinical presentation and imaging 
 were concerning for an incarcerated paraesophageal hernia , and the patient was taken to the operating room . during laparoscopic reduction of the hernia and repair , 
 chyle was encountered in the peritoneal cavity , mediastinum and pleural spaces . 
 postoperatively , the chyle leak resolved with a nonfat diet . 
 the unusual occurrence of a chyle leak in this case may have been due to compression of the thoracic duct within the chest by the incarcerated paraesophageal hernia .