A Rare Case of Small Bowel Volvulus with Chylous Ascites Presumed to Be Caused by Multiple Congenital Adhesions in a Virgin Abdomen: A Case Report and Literature Review.

INTRODUCTION: Chylous ascites is an uncommon condition resulting from triglyceride-rich lymphatic fluid leakage into the peritoneal cavity and is typically diagnosed when the ascitic triglyceride level is ≥200 mg/dL. Small bowel volvulus is an uncommon surgical emergency, and its coexistence with chylous ascites is particularly rare. Postoperative adhesions are a common cause of small bowel volvulus; however, small bowel volvulus caused by adhesions presumed to be congenital in a virgin abdomen is infrequently reported. Herein, we report a case of small bowel volvulus associated with chylous ascites in which the adhesions were most consistent with congenital origin, although definitive differentiation was not possible.

CASE PRESENTATION: A 61-year-old male with no history of abdominal surgery presented with sudden-onset abdominal pain. Contrast-enhanced CT revealed a whirl sign in the mesentery with mild ascites. Emergency exploratory laparotomy revealed milky-white ascites and 360° volvulus at the root of the small bowel mesentery. Multiple adhesions, presumed to be congenital based on the absence of prior surgery or documented inflammation, were identified as the underlying cause of the volvulus. All adhesions were carefully divided; de-torsion alone was sufficient, and bowel resection was unnecessary. Biochemical analysis of the ascitic fluid revealed a triglyceride level of 200 mg/dL, which confirmed the diagnosis of chylous ascites. The patient recovered uneventfully and remained recurrence-free for 6 months.

CONCLUSIONS: This report describes a rare case of small bowel volvulus accompanied by chylous ascites presumed to be caused by multiple congenital adhesions in a virgin abdomen. Although causal relationships cannot be definitively established, this case highlights important considerations regarding intraoperative assessment of bowel viability and adhesions. The presence of chylous ascites alone should not be regarded as a reliable indicator of bowel ischemia; careful surgical evaluation remains essential.