A curious case of ascites. Chylous ascites caused by Kaposi's sarcoma.
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Acquired Immunodeficiency Syndrome↗
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Dilated cardiomyopathy associated with chylous ascites.
Chylous ascites is a well-documented sequelae of traumatic rupture of the thoracic duct and mechanical obstruction of the lymphatic system due to neoplastic, inflammatory, or congenital anomalies. Less commonly, chylous ascites results from altered hemodynamics and lymphatic flow, as seen in cirrhosis and constrictive pericarditis. Rarely, severe right-sided heart failure from a variety of causes has also resulted in chylous ascites or a protein-losing enteropathy. We report a case of chylous ascites due to dilated cardiomyopathy with autopsy findings. The pathophysiology of chylous ascites formation in right heart failure will be discussed, with a review of the literature.
Aged↗
Use of orlistat (xenical) to treat chylous ascites.
Chylous ascites is uncommon and occurs in about 1 in 20,000 hospital admissions. Causes include disruption of the lymphatic system due to malignancy, cirrhosis, surgery, or radiation therapy. The mainstay of therapy has been low-fat diet supplemented with medium-chain triglyceride oil. However, dietary compliance can be difficult to achieve for adequate response. We report a 47-year-old man with hepatitis C and alcohol-related cirrhosis with new-onset chylous ascites and chylothorax. His ascites triglyceride was 585 mg/dL, and the pleural fluid triglyceride was 691 mg/dL. Ascitic and pleural fluid cytology and acid-fast bacilli stain were negative. The patient was treated with low-fat diet and medium-chain triglyceride oil. However, his ascites remained chylous after 1 week of treatment because of poor compliance with the dietary restrictions. Orlistat was then added to his treatment regimen. A half week later, the chylous component of his ascites resolved. Remaining high-volume clear ascites was treated with placement of a transjugular intrahepatic portosystemic shunt. To our knowledge, orlistat has never been used in the treatment of chylous ascites. This case suggests the potential value of adding orlistat to low-fat diet and medium-chain triglyceride oil in the treatment of chylous ascites, especially in patients who are unable to comply with the dietary restrictions.
Chylous Ascites↗
Peri-operative chylous ascites.
Chylous ascites occurs when lymphatics are disrupted due to primary lymphatic disease, infection, malignancy, or chronic liver disease. It may also occur following inadvertent interruption of abdominal lymphatics during surgery involving retroperitoneal dissection. It is suggested by some that during liver transplantation, severed hepatic lymphatics should be ligated or stented to avoid post-operative pleural and abdominal accumulation of chylous fluid. The occurrence of chylous ascites and the need to ligate lymphatics after orthotopic transplantation was assessed in 180 consecutive patients subjected to this procedure. Pre-operative chylous ascites present in one patient resolved following transplantation. Three patients who required retroperitoneal dissection to complete the biliary anastomosis via choledochojejunostomy or perform a hepatic artery graft developed post-operative chylous ascites which rapidly resolved without complications. These findings indicate special attention to transacted hepatic lymphatics is not required during orthotopic liver transplantation. Chylous ascites rarely occurs after liver transplantation and its transitory development is due to retroperitoneal dissection.
Aged↗
[Acute peritonitis: a rare presentation of chylous ascites].
Chylous ascites is a rare case of peritonitis. We report here a case arising in a 21-year-old lady.
Abdominal Pain↗
Diagnosis and management of primary chylous ascites.
BACKGROUND: Chylous ascites is the accumulation of triglyceride-rich, free, milk-like peritoneal fluid caused by the presence of intestinal lymph in the abdominal cavity. Primary chylous ascites is uncommon. We present our experience in the diagnosis and treatment of this condition. METHODS: Twelve patients (7 adults, 5 children) affected by primary chylous ascites were studied. Diagnostic investigations included abdominal sonography scans, lymphoscintigraphy, and lymphography combined with computed tomography (CT) with intravenous and intralymphatic lipid-soluble contrast, and laparoscopy. Magnetic resonance imaging was used when lymphography and lymphatic CT were not able to define the dysplasia well, or in the presence of lymphatic dilatation. Surgical treatment included laparoscopy (12/12), drainage of ascites (12/12), the search for and treatment of abdominal and retroperitoneal chylous leaks (12/12), exeresis of lymphodysplastic tissues (12/12), ligation of incompetent lymph vessels (9/12), carbon dioxide laser treatment (cut and welding effects) of the dilated lymph vessels using an operating microscope for magnification (9/12), and chylovenous and lymphovenous microsurgical shunts (7/12). RESULTS: Eight patients did not have a relapse of the ascites, and three patients had a persistence of a small quantity of ascites with no protein imbalance. Postoperative lymphoscintigraphy in seven patients confirmed better lymph flow and less lymph reflux. Median follow-up was 5 years (range, 3 to 7 years). We observed early relapse of chylous ascites in only one case that required a peritoneal-jugular shunt and led to good outcome. CONCLUSION: Primary chylous ascites is closely correlated to lymphatic-lymphonodal dysplasia that does not involve a single visceral district alone. Medical preoperative treatment played an essential role in the global management of this complex pathology. We demonstrated that the use of laparoscopy is remarkably advantageous for confirming diagnosis, for draining the ascites, and for evaluating the extension of the dysplasia. Our diagnostic work-up provided us with an exact diagnostic assessment and allowed us to plan a precise surgical approach.
Adult↗
The diagnosis and management of postoperative chylous ascites.
PURPOSE: Postoperative chylous ascites is a rare complication of retroperitoneal and mediastinal surgery that represents a difficult management problem due to the serious mechanical, nutritional and immunological consequences of the constant loss of protein and lymphocytes. We reviewed the topic of postoperative chylous ascites with special emphasis on the relevant diagnostic and imaging modalities. We propose a novel management algorithm. MATERIALS AND METHODS: We performed a MEDLINE search of the literature on chylous ascites using chyloperitoneum as the subject heading and chylous ascites as an additional key word. The search yielded 651 articles. We focused on 102 series, collective reviews and mainly case reports related to the issue of postoperative chylous ascites. RESULTS: We propose a novel algorithm based on a step-up approach aimed at promoting decreased lymph production and flow as well as maintaining nutritional balance. The management algorithm integrates repeat palliative paracentesis, dietary measures, total parenteral nutrition therapy, peritoneovenous shunting and surgical closure of the lymphoperitoneal fistula. Due to the remarkable effectiveness of somatostatin therapy for the closure of lymphatic fistula somatostatin therapy should be attempted with or without total parenteral nutrition early in the course of treatment of chylous ascites before any invasive steps are taken. CONCLUSIONS: Various management modalities may be used successfully to treat chylous ascites. Therefore, treatment should be individualized and adjusted to the severity of lymphatic leakage and its consequences. The outcome mostly depends on the underlying pathological condition. Thus, in the absence of malignant or congenital underlying pathology the prognosis in cases of postoperative chylous ascites is good with the majority responding to conservative measures.
Adult↗
Total parenteral nutrition in the management of traumatic chylous ascites in infancy.
Chylous ascites is rare in the pediatric age group and usually of unknown etiology or due to congenital abnormalities of the lymphatic system. This report describes an infant with posttraumatic chylous ascites, unable to tolerate dietary therapy, in whom total parenteral nutrition allowed successful management. The experience gained in this case clarifies the management of chylous ascites from all causes. Specific recommendations for a treatment protocol are made.
Battered Child Syndrome↗
[Chylous ascites in infancy].
Chylous ascites is a rare disease in infancy. Onset with acute manifestations should be managed surgically. However, congenital in nature or chronic cases many be treated conservatively with either medium-chain triglyceride feedings or total parenteral nutrition. Five cases of infantile chylous ascites are reported and discussed here.
Chylous Ascites↗
[Chylous ascites secondary to liver cirrhosis, with special reference to lymphangiography and lipoprotein analysis of chylous ascites].
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Chylous Ascites↗
Octreotide in the outpatient therapy of cirrhotic chylous ascites: a case report.
Chylous ascites is a rare complication of liver cirrhosis associated with a poor short-term prognosis. We report the case of an 80-year-old male cirrhotic patient with refractory chylous ascites associated with portal hypertension. He was treated with total parenteral nutrition but chylous ascites relapsed at suspension. Patient was put on long-term subcutaneous octreotide (100 microg t.i.d.) as an outpatient. The treatment was well tolerated and led to clinical improvement, markedly reducing the need of total paracentesis and the amount of ascites. Octreotide was stopped after 6 months, and massive ascites did not relapse. After 1 year the patient was alive, with no need of paracentesis. Octreotide therapy should be considered in patients with cirrhosis and chylous ascites to simplify the outpatient management of the disease.
Aged, 80 and over↗
Analysis of genetic control of chylous ascites in ragged mice.
Chylous ascites is a disorder visible as a white fluid in the peritoneal cavity of suckling mice. It is due to inadequate lymphatic drainage from the small intestine. An initial genetic study showed it to be a pleiotropic effect of ragged, Ra. There were four main studies. These involved seven major mutants segregating with ragged. Four of the mutants had no effect on chylous ascites, but two mutants linked with ragged, and one unlinked, showed a complex situation involving enhancement, inhibition, epistacy and other interactions. The overall phenotypic effects which these mutants are known to have do not explain how they produce their interaction with ragged in terms of chylous ascites. The studies also indicate the existence of a single major modifier controlling penetrance and expression, and there is evidence for cumulatively acting minor modifiers. In neonates the male sex is more liable to chylous ascites, and in adults this condition affects fertility and fecundity.
Animals↗
Chylous ascites in three dogs.
Chylous ascites was diagnosed in 3 dogs. Mesenteric lymphangiography was performed in 2 dogs and helped delineate abnormalities of the lymphatic system. The cause of chylous ascites in each dog appeared to be different. In 1 dog, a ruptured mesenteric lymphatic was identified at surgery. Evidence of abdominal lymphatic obstruction was found in another dog. Chylous ascites in the third dog appeared to be a complication of mesenteric lymphangiography for chylothorax.
Animals↗
[Postoperative chylous ascites in urology].
Postoperative chylous ascites is a rare complication after retroperitoneal surgery. It is a complex problem associated with nutritionnal and immunological consequences. Urologists should be able to manage this complication linked to many urological procedures. Incidence of chylous ascites seems to increase with time probably because more complex surgical interventions. Diagnosis is usually suspected based on clinical abdominal symptoms. Diagnostic paracentesis shows milky fluid with high triglyceride and lymphocyte content. Treatment is classicaly based on dietary interventions with the goal to decrease fistula's lymph flow. Somatostatin analog is a very efficient adjuvant therapy and should be used early in the course of treatment. Surgery is usually attempted in patients who have failed conservative modalities. Because chylous ascites is rare, no clear management guidelines exist. Treatment should be individualized and tailored according to severity of lymphatic leakage, its consequences and the patient health status.
Chylous Ascites↗
Chylous ascites caused by constrictive pericarditis.
Chylous ascites is an uncommon clinical entity associated with lymphatic obstruction usually caused by underlying malignancy. The authors describe a patient with chylous ascites caused by constrictive pericarditis in the absence of mechanical lymphatic obstruction. Pathophysiological mechanisms for the development of chylous ascites in constrictive pericarditis include augmented lymph production and high impedance to lymph drainage caused by central venous hypertension. After pericardiectomy, the patient's ascites and edema resolved. Constrictive pericarditis should be considered a rare but potentially curable cause of chylous ascites.
Chylous Ascites↗
Chylous ascites in infants and children.
Chylous ascites in infants and children has been the subject of 35 articles in the English language literature during the past 30 years. Analysis of the cases of 58 patients reveals that chylous ascites has been reported twice as frequently in infants as in older children, but that the clinical presentations, essentials of diagnosis, treatment alternatives, and mortality rates have been otherwise remarkably similar. Two thirds of patients treated without operation were cured, half of them within the first month of therapy. Even though the documented experience with total parenteral nutrition in infants and children with chylous ascites is remarkably scant, parenteral nutritional support appears to have decreased the hazard of medical therapy by maintaining an adequate nutritional intake while eliminating obligate losses consequent to repeated paracentesis. Patients in whom chylous ascites recurs, after resumption of a regular diet, should undergo surgical exploration, according to a defined strategy that includes visualization of the retroperitoneal origin of the superior mesenteric artery.
Child, Preschool↗
Chylous ascites in acute pancreatitis during pregnancy: case report.
Chylous ascites is a rare clinical manifestation characterized by ascitic chylomicrons resulting from mechanical obstruction of or leakage from the lymphatic channel. Chronic disorders, especially malignancies, account for most cases of chylous ascites. Acute chylous ascites is less common than the chronic form. We present a rare case of acute chylous ascites secondary to acute pancreatitis during the third trimester of pregnancy. This 24-year-old woman was referred to our emergency department because of severe epigastralgia for several days. Abdominal computed tomography revealed diffuse enlargement of the pancreas and peripancreatic exudation. Massive chylous ascites was found during emergent abdominal exploratory laparotomy. An emergent cesarean section was done because of fetal distress and there was no further accumulation of chyle. A pancreaticocutaneous fistula resulting from the cesarean section was treated successfully with a fistulectomy. In conclusion, chylous ascites is a rare complication of acute pancreatitis. Cesarean section may be helpful in terminating chylous accumulation in acute pancreatitis during the third trimester of pregnancy.
Acute Disease↗
[Chylous ascites in cirrhosis. Retrospective study of 20 cases].
Chylous ascites is a rare complication of cirrhosis. We report 20 cirrhotic patients with chylous ascites seen between 1976 and 1989. Hepatocellular carcinoma was associated in 2 cases and, in 5 cases, chylous ascites followed surgery (portosystemic shunt in 4 cases). Chylous ascites was spontaneous in the 13 other cases. Prevalence of chylous ascites was 1.1 p. 100 in the cirrhotic population with ascites observed between 1983 and 1988. Chylous ascites, whether spontaneous or postoperative, was almost always refractory to medical treatment (16 of 18 patients). Treatment by Le Veen shunt was unsuccessful in 4 patients and lead to infection in 2 cases. Four of 6 patients treated by portocaval shunt died during the first postoperative month. Repeated paracentesis should be preferred, but this can be complicated by malnutrition. Seven of 10 alcoholic cirrhotics with spontaneous chylous ascites and 2 of 4 patients with postoperative chylous ascites died during the year following diagnosis. In view of this poor prognosis, hepatic transplantation should be considered early in selected patients.
Adult↗