a 55 yr old man with a adenocarcinoma of the head of pancreas , after whipple surgery on the third day of post surgery showed diffuse edema , ascites and left plural effusion. bilirubin ,amylase and triglyceride of ascites was normal.
patient albumin before and after surgery was 4.1 and 2 mg/dl. patient condition is ok and enteral feeding was started on day 5 post operation and was tolerated by him with normal (non fatty) defecation but albumin with TPN increased to 2.9.
kidney ,liver and heart situation and function was evaluated and was normal. the patient had not remarkable past history.
drain secretion was tested and no leak evidence was detected .
Hypoproteinemia as a result of catabolic processes + hyperhydratation.
I am agree with the previous posts: it is seemingly a sum of parenteral fluid overload and low serum albumin level (2 mg/dL is low). Had the patient had any chemotherapy and/or corticosteroid treatment before or after the surgery?
Additionally, it would be good to check
- Na+/K+ and Cl- serum levels;
- Routine urine analysis (primarily for a massive proteinuria to exclude or confirm)
Good luck!
I am sure that this question remains for you after check out some routine answers to causes of edema such as Hypoproteinemia, volume overload and etc.
I think your are looking for a specific cause!
1-previous treatment with gemcitabine which can cause gemcitabine-associated systemic capillary leak syndrome
http://www.ncbi.nlm.nih.gov/pubmed/18176375
2-acute necrotising pancreatitis
http://www.ncbi.nlm.nih.gov/pubmed/19382054
3-clot formation in IVC / mass effect of a local edema on port or IVC
THANKS FOR REPLIES
as mentioned before we checked the renal,liver and heart function for probably reasons of edema and Na ,K also was normal.
patient has no pervious chemotherapy!
edema also was generalized .
and as dr esfehani mentioned, if IVC had clot the low serum albumin cannot be explained !
in case of acute necrotizing pancreatitis , we expect a very bad condition of patient with abdominal pain and ileus that our patient has a very good condition
As Dr.Esfehani has mentioned above, it may be a post-operative pancreatitis.
Indeed, a necrotizing spot or lesions of other kind in the pancreatic stump may have been existing for long with minimal manifestations. It may be one of the most insidious complication in abdominal surgery at times.
In other patients, it may develop as the result of a vast retroperitoneal lymphodissection lead to a massive lymphorrhea through drain tubes and depletion of the serum albumin due to the loss of the lymph. It may be amazing at some case how much lymph would produce the retroperitoneal space!
Did you check ABG?
Acidosis, alkalosis and supine position can induce edema and water retention.
The analysis of ascites fluid excludes chylorea. But left-sided idiopathic chylothorax may also explain the quick loss of protein.
Thanks for your replies
as mentioned in question the triglyceride of drain was normal and patient has no abdominal comfort besides patient has defecation and CT scan of abdomen reveal normal imaging in retroperion and normal pancreas.
DEAR volodymyr
all analysis shows no remarkable finding and albumin was low
It is very likely due to hypo albunemia.The preexisting malnutrition and hypoalbuminemia must have got worse post surgery.These should settle well with Albumin infusion and NJ feeds.One should watch for anastamotic problems.
edema of the patient after surgery reduce gradually.now he is in a very good condition.no edema in lower exterimity.
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