chronic chylous ascites , associated with malignant obstructions in the lymphatic channel , does not usually cause acute abdominal pain . that is , chyle extravasation into the peritoneal cavity is rarely associated with the sudden development of peritonitis ( 1 ) . we present a case of acute chylous peritonitis in a patient with advanced gastric carcinoma who presented with signs and symptoms of peritonitis caused by ovarian torsion . the department of surgery was consulted for the finding of milky peritoneal fluid in a 41-yr - old female undergoing a complete abdominal hysterectomy with bilateral salphingo - oophorectomy ( tah - bso ) by a gynecologist at our institution . the patient had been admitted to the yonsei university medical center , seoul , korea , for chemotherapy due to advanced gastric carcinoma . a previous computed tomography ( ct ) scan had shown bilateral metastatic ovarian tumors . during her stay , a physical examination revealed direct tenderness to palpation , rebound tenderness , and guarding ; she was also noted to have a palpable left supraclavicular node . a chest radiography was normal ; an emergent abdominal pelvic ct scan showed increased bilateral ovarian tumors with minimal intraperitoneal fluid collection ( fig . the initial blood laboratory results showed a total leukocyte count of 3,600/l with 58% neutrophils , hb 12.8 g / dl , platelet count 245,000/l , na 143 mm / l , k 3.9 mm / l , cl 103 mm / l , bun 13.6 mg / dl , creatinine 0.9 mg / dl , glucose 116 mg / dl , ast 20 iu / l , alt 14 iu / l , and total bilirubin 0.6 mg / dl . based on the physical examination and ct findings , peritonitis caused by ovarian torsion was strongly suspected , leading a gynecologist to perform an exploratory laparotomy on an emergency basis . in the operative field , however , a minimal to moderate amount of milky peritoneal fluid was observed in the pelvic cavity and along the right paracolic gutter . after the tah - bso , the patient was evaluated at the department of surgery for chylous ascites . on intraperitoneal exploration , the stomach seemed to be tethered to the pancreas , but there was no evidence of peritoneal carcinomatosis . diffuse lymphatic ectasia and milky fluid discharge were noted around the small bowel mesentery ( fig . she was given a fat - free diet , and no evidence of reoccurrence of ascites was noted on clinical observation , such as the measurement of daily body weight and abdominal circumference . chylous ascites is an uncommon finding , with an incidence of 1 in 20,000 hospital admissions ( 2 ) . paracentesis is the most important diagnostic modality and reveals milky peritoneal fluid with a triglyceride concentration 2 to 8 times that of plasma ( 3 ) . malignant lymphoma is the most common cause of chylous ascites and accounts for 50% of cancer - related cases ( 4 ) . malignant invasion causes lymphatic channel fibrosis and disruption of the peritoneal cavity lymphatic system , enhancing extravasation distal to the obstruction . other malignancies such as colon , pancreatic , stomach , ovarian cancers , and intestinal carcinoid , kaposi sarcoma , and lymphangiomyomatosis ( 5 ) can also cause chylous ascites . other etiologies include infectious diseases , such as peritoneal tuberculosis and lymphatic filariasis , lymphatic system congenital anomalies , radiation side effects , abdominal surgery complications , and portal hypertension from liver cirrhosis ( 6 ) . chronic chylous ascites usually does not present with acute abdominal pain , as mentioned previously . in the present case , the abrupt onset was accompanied by peritoneal signs that led to an emergency exploratory laparotomy due to a concern of ovarian torsion caused by large bilateral ovarian krukenburg 's tumors . strictly speaking , the operative finding did not show any evidence of acute inflammatory changes in the patient 's peritoneal cavity ; however , clinical symptoms definitively suggested peritonitis , requiring immediate surgical intervention . therefore , the diagnosis of acute chylous peritonitis may be more appropriate than that of chylous ascites , depending on the clinical setting . although there was no gross lymphadenopathy or peritoneal cancer seeding , microscopic metastasis in the small lymphatic system was suspected as the etiology . later it was revealed that the patient had left supraclavicular engorgement , which subsequently decreased after the laparotomy . disruption of the abdominal cavity peripheral lymphatic system , caused by thoracic duct obstruction from a metastatic left clavicular lymph node , resulted in sudden extravasation and acute chylous peritonitis . in our hypothesis , if it had not been for the chylous ascites , the abrupt onset of chylothorax might have occurred , and would have presented with dyspnea as the initial symptom . the optimal management of chylous ascites includes a protein - rich , low - fat diet , medium - chain triglycerides , sandostatin , and orlistat ( xenical ) ( 7 - 10 ) . total parenteral nutrition can be used to decrease lymphatic flow and to promote lymphatic disruption closure . although no drain catheters were placed , there was no evidence of further peritoneal fluid collection . in this case , the symptoms and signs of peritonitis were present ; however , there was no accompanying fever , leukocytosis , or intraperitoneal free air . although spontaneous acute chylous peritonitis is rare , the disease should be considered in a patient with underlying malignant disease and signs of peritoneal irritation without associated leukocytosis , fever , and intraperitoneal free air . in these cases , laparoscopy prior to laparotomy would have confirmed chylous ascites and resulted in a less invasive surgical procedure .