Chylous ascites

Chylous ascites also known as chyloperitoneum, is a rare form of ascites caused by accumulation of milky lymphatic fluid with a triglyceride level >110 mg/dL in the peritoneal cavity and is caused by disruption of the lymphatic system from any cause ¹. Chylous ascites is usually due to intra-abdominal malignancy, liver cirrhosis or abdominal surgery complications, and present with painless but progressive abdominal distension, dyspnea and weight gain ².

Chylous ascites causes

Chylous ascites is an uncommon clinical condition that occurs as a result of disruption of the abdominal lymphatics. Chylous ascites may be divided into traumatic and atraumatic causes (Table 1). Multiple causes have been described, with the most common causes being abdominal malignancy (hepatoma, small bowel lymphoma, small bowel angiosarcoma, and retroperitoneal lymphoma), cirrhosis (≤0.5% of patients with ascites from cirrhosis may have chylous ascites), and trauma after abdominal surgery ³ in developed countries and account for over two-thirds of all cases, whereas chronic infections like tuberculosis and filariasis account for the majority of the cases in developing countries ⁴.

Other causes include the following:

• Blunt abdominal trauma
• Spontaneous bacterial peritonitis
• Pelvic irradiation
• Peritoneal dialysis
• Abdominal tuberculosis
• Carcinoid syndrome
• Congenital defects of lacteal formation

Table 1. Etiological classification of chylous ascites

Atraumatic		Traumatic
(I) Neoplastic	Cardiac	(I) Iatrogenic
Solid organ cancers	Constrictive pericarditis	(A) Surgical
Lymphoma	Congestive heart failure	Abdominal aneurysm repair
Sarcoma	Gastrointestinal	Retroperitoneal lymphadenectomy
Carcinoid tumors	Celiac sprue	Placement of peritoneal dialysis catheter
Lymphangioleiomyomatosis	Whipple’s disease	Inferior vena cava resection
Chronic lymphatic leukemia	Intestinal malrotation	Pancreaticoduodenectomy
(II) Diseases	Small bowel volvulus	Vagotomy
(A) Congenital	Ménétrier disease	Radical and laparoscopic nephrectomy
Primary lymphatic hypoplasia	Inflammatory	Nissen fundoplication
Klippel-Trenaunay syndrome	Pancreatitis	Distal splenorenal shunts
Yellow nail syndrome	Fibrosing mesenteritis	Laparoscopic adrenalectomy
Primary lymphatic hyperplasia	Retroperitoneal fibrosis	Gynecological surgery
Lymphangioma	Sarcoidosis	(B) Nonsurgical
Familial visceral myopathy	Systemic lupus erythematosus	Radiotherapy
(B) Acquired	Behçet’s disease	(II) Noniatrogenic
Cirrhosis	Peritoneal dialysis	Blunt abdominal trauma
Infectious	Hyperthyroidism	Battered child syndrome
Tuberculosis	Nephrotic syndrome	Penetrating abdominal trauma
Filariasis	Drugs	Shear forces to the root of the mesentery
Mycobacterium avium in AIDS	Calcium channel blockers	(III) Idiopathic
Ascariasis	Sirolimus	Rule out lymphoma

[Source ⁵ ]

In adults, chylous ascites is associated most frequently with malignant conditions. These conditions particularly include lymphomas and disseminated carcinomas from primary neoplasms in the pancreas, breast, colon, prostate, ovary, testes, and kidney. Infectious diseases, such as tuberculosis ⁶ and filariasis ⁷ can cause chylous ascites. Chylous ascites has also been reported in adults in association with hepatoma, small bowel angiosarcoma, retroperitoneal lymphoma, jejunal carcinoid ⁸ and sclerosing mesenteritis ⁹.

In children, the most common causes of chylous ascites are congenital abnormalities, such as lymphangiectasia, mesenteric cyst, and idiopathic “leaky lymphatics.” Other congenital causes include primary lymphatic hypoplasia associated with Turner syndrome and yellow nail syndrome, and the lymphatic malformations associated with Klippel-Trenaunay syndrome ¹⁰. Lymphatics may spontaneously rupture in patients with cirrhosis as a result of higher than typical flow, with the formation of chylous ascites. Chylous ascites has been reported in patients with polycythemia vera and resulting hepatic vein thrombosis.

Abdominal surgery is a common cause of chylous ascites. The most frequently associated surgical procedures are resection of abdominal aortic aneurysm and retroperitoneal lymph node dissection. In a series of 329 patients with testicular cancer who underwent postchemotherapy retroperitoneal lymph node dissection, 7% of patients developed chylous ascites ¹¹. Chylous ascites has also been described after several abdominal procedures, such as peritoneal dialysis catheter insertion ¹², pancreatic resection ¹³, splenorenal shunt surgery ¹⁴, cadaveric ¹⁵ and living donor liver transplantation ¹⁶, laparoscopic donor nephrectomy ¹⁷ and laparoscopic Nissen fundoplication.

Chylous ascites pathophysiology

The principal mechanisms for chylous ascites formation are related to disruption of the lymphatic system, from any cause. Three basic mechanisms have been proposed using lymphangiography and inspection at laparotomy ¹⁸:

1. Exudation of lymph through the walls of retroperitoneal megalymphatics into the peritoneal cavity, which occurs with or without a visible fistula (i.e., congenital lymphangiectasia),
2. Leakage of lymph from the dilated subserosal lymphatics on the bowel wall into the peritoneal cavity which is due to malignant infiltration of the lymph nodes obstructing the flow of lymph from the gut to the cisterna chili,
3. Direct leakage of lymph through a lymphoperitoneal fistula associated with retroperitoneal megalymphatics due to acquired lymphatic disruption as a result of trauma or surgery.

In addition, the increased caval and hepatic venous pressures caused by constrictive pericarditis, right-sided heart failure, and dilated cardiomyopathy may precipitate chylous ascites through large increase in production of hepatic lymph ¹⁹. Finally, cirrhosis also causes an increased formation of hepatic lymph ²⁰. In fact, decompression of the portal vein in patients with portal hypertension has been shown to relieve lymphatic hypertension ²¹.

Chylous ascites symptoms

Abdominal distention is the most common symptom in patients with chylous ascites. Other clinical features include abdominal pain, anorexia, weight loss/gain, edema, weakness, nausea, dyspnea, lymphadenopathy, early satiety, fever, and night sweats. Fever, night sweats, and lymphadenopathy are usually observed in patients with lymphoma. Often, features of the primary illness, such as cirrhosis or of an associated malignancy, dominate the clinical picture. Rarely, it can present as acute peritonitis ²² or as a consequence of acute gallstone pancreatitis ²³.

Chylous ascites clinical presentation:

• abdominal distension
• abdominal discomfort
• dyspnea: splinting of the diaphragm by ascites
• sequelae of hypoproteinemia: edema
• acute abdomen: acute chylous peritonitis ⁷

For fluid aspirated from the abdomen to be chyle, triglycerides need to be elevated above 110 mg/dL (two to eightfold more than normal plasma concentration) with a specific gravity >1.012.

Chylous ascites complications

Sepsis is the most common complication, and sudden death has been reported in patients with chylous ascites.

Loss of chyle into peritoneal cavity can lead to serious consequences because of the loss of essential proteins, lipids, immunoglobulins, vitamins, electrolytes, and water. While repeated therapeutic paracentesis provides relief from symptoms, the nutritional deficiency will continue to persist or deteriorate unless definitive therapeutic measures are instituted to stop leakage of chyle into the peritoneal space. In fact, in postoperative settings, this may cause increased mortality ²⁴. Therefore, it is very important to provide adequate nutritional support replenishing fluid loss, vitamin deficiencies, and electrolyte loss while specific therapeutic measures are planned.

In addition, continued loss of lymphocyte-rich lymph into the peritoneal space and enormous loss of protein in gastrointestinal tract lead to hypogammaglobulinemia and therefore increased susceptibility to infection ²⁵. Prolonged thoracic duct drainage has been used previously to induce immunosuppression in several diseases including rheumatoid arthritis and myasthenia gravis ²⁵.

The bioavailability of certain drugs could be drastically impaired in the presence of significant chyle leak. There are reports of this phenomenon in patients with chylothorax-causing subtherapeutic digoxin ²⁶, amiodarone ²⁷ and cyclosporine ²⁸ levels in the serum. Sequestration of drugs in chyle should be recognized early, to prevent subtherapeutic plasma levels in patients undergoing drainage of chylous ascites.

Chylous ascites diagnosis

The diagnostic approach of chylous ascites consists of first suspecting the diagnosis, then confirming the presence of chyle in the peritoneal cavity, and finally determining the underlying abnormality. A careful history, physical examination, and diagnostic paracentesis are the key in the initial evaluation of any patient presenting with ascites.

Abdominal paracentesis is the most important diagnostic tool in evaluating and managing patients with ascites. In contrast to the yellow and transparent appearance of ascites due to cirrhosis and portal hypertension, chyle typically has a cloudy and turbid appearance (see Table 2 below). This should be distinguished from pseudochylous ascites, in which the turbid appearance is due to cellular degeneration from infection or malignancy without actually containing high levels of triglycerides ²⁹. Depending on the clinical suspicion, ascitic fluid should be sent for cell count, culture, Gram stain, total protein, albumin, triglyceride levels, glucose, lactate dehydrogenase, amylase, and cytology ³⁰. The serum to ascites albumin gradient (SAAG) should be calculated to determine if the ascites is related to portal hypertension or other causes ³⁰. The triglyceride levels in ascitic fluid are very important in defining chylous ascites. Triglyceride values are typically above 200 mg/dL, although some authors use a cutoff value of 110 mg/dL ³¹. A tuberculosis smear and culture and adenosine deaminase activity should be performed in selected cases when tuberculosis is suspected ³¹. Adenosine deaminase activity has high sensitivity and specificity in the diagnosis of tuberculous peritonitis ³². In contrast, its utility in populations with high prevalence of cirrhosis such as the United States is limited ³³. The diagnosis of tuberculous peritonitis usually requires a peritoneal biopsy via laparoscopy ³⁴.

Laboratory studies

Routine laboratory tests may show hypoalbuminemia, lymphocytopenia, anemia, hyperuricemia, elevated levels of alkaline phosphatase and liver enzymes, and hyponatremia. Serum cholesterol and triglyceride levels are usually normal.

Abnormal liver enzyme levels are more common in patients with disseminated carcinoma than in patients with lymphoma or nonmalignant disorders. Anemia is common in patients with neoplasia.

The diagnosis of chylous ascites is made by peritoneocentesis and by analysis of the ascitic fluid. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites ³.

Ascitic fluid study

Ascitic fluid is usually white or milky. Gross milkiness of the ascitic fluid corresponds poorly with absolute triglyceride levels, because turbidity also reflects the size of the chylomicrons.

The ascites triglyceride level is elevated in all patients. Typically, chylous ascites is diagnosed when the ascites triglyceride level is greater than 110 mg/dL. Levels as high as 8100 mg/dL have been described ³⁵. Other authors have identified an elevated ascites-to-plasma triglyceride ratio (between 2:1 and 8:1) as being indicative of chylous ascites ⁷.

Table 2. Characteristics of ascitic fluids in chylous ascites

Color	Milky and cloudy
Triglyceride level	Above 200 mg/dL
Cell count	Above 500 (lymphocytic predominance)
Total protein	Between 2.5 and 7.0 g/dL
Serum-ascites albumin gradient	Below 1.1 g/dL (is elevated above 1.1 g/dL in chylous ascites secondary to cirrhosis)
Cholesterol	Low (ascites/serum ratio < 1)
Lactate dehydrogenase	Between 110 and 200 IU/L
Culture	Positive in selected cases of tuberculosis
Cytology	Positive in malignancy
Amylase	Elevated in cases of pancreatitis
Glucose	Below 100 mg/dL

Other ascites tests include the following ³⁵:

• The specific gravity is 1.010-1.054.
• Total fat content is 4-40 g/L.
• Glucose and amylase levels are usually normal.
• Cholesterol level is usually low.
• The leukocyte count is generally high (232-2560 cells/mm3), usually with a marked lymphocytic predominance.
• The total protein content varies from 1.4 to 6.4 g/dL, with a mean of 3.7 g/dL. This variation reflects changes in serum proteins and dietary habits.
• Microbiologic cultures are usually negative

Other diagnostic tests

Other studies may be indicated, such as the following:

• Computed tomography (CT) scanning
• Lymph node biopsy
• Laparascopy
• Laparotomy
• Lymphangiography
• Bone marrow examination
• Intravenous pyelography

CT scanning, lymph node biopsy, and laparotomy carry the highest yield of diagnostic information. The role of magnetic resonance imaging (MRI) is not well defined. Note that lymphangiography can transiently worsen chylous ascites due to the oily contrast medium used for the test.

Chylous ascites treatment

Because chylous ascites is a manifestation rather than a disease by itself, the treatment depends on the underlying disease or cause ³.

Supportive measures can relieve the symptoms. These measures include repeated paracentesis, diuretic therapy, salt and water restriction, elevation of the legs and the use of supportive stockings, and dietary measures.

Lymphatic flow increases after the ingestion of a fatty meal. The fatty acids derived from short-chain and medium-chain triglycerides diffuse directly across enterocytes into the portal venous system. Their absorption does not affect lymphatic flow. However, the fatty acids derived from long-chain triglycerides are re-esterified into triglycerides in the enterocyte. They are then incorporated into chylomicrons which subsequently enter the lymphatic system.

A low-fat diet with medium-chain triglyceride supplementation can reduce the flow of chyle into the lymphatics ³⁶. Typically, medium-chain triglyceride oil is administered orally at a dose of 15 mL three times per day with meals. However, this approach is frequently not successful. One case report described the successful use of orlistat (Xenical) in a patient who had difficulty complying with a low-fat diet ³⁷.

If chylous ascites persists despite dietary management, the next step may involve bowel rest and the institution of total parenteral nutrition ³⁸. Bowel rest and total parenteral nutrition are postulated to be beneficial in patients with posttraumatic or postsurgical chylous ascites.

Paracentesis can result in immediate symptom relief; however, reaccumulation of fluid usually follows, and patients may require repeated paracentesis. Some authorities have advocated large-volume paracentesis. Morbidity from a single tap is usually low, but complications (eg, peritonitis, hemorrhage) can occur. Transfusion of albumin and/or red blood cells (RBCs) during paracentesis may help prevent hypovolemia in patients with hypoalbuminemia or anemia.

Multiple case reports describe the use of octreotide, a somatostatin analogue, in the management of chylous ascites, typically at a dose of 100 mcg administered subcutaneously three times per day ³⁹. A combination of total parenteral nutrition and subcutaneous octreotide has been used successfully to treat congenital chylous ascites in a newborn ⁴⁰. Experimental work in humans has shown that somatostatin can significantly decrease postprandial increases in triglyceride levels. This effect cannot be explained by either inhibition of gastric emptying or inhibition of exocrine pancreatic secretion ⁴¹. Octreotide is most likely effective in chylous ascites owing to its ability to inhibit lymphatic flow. Indeed, in a canine model, infusion of somatostatin resulted in a decrease in lymph flow, measured via a cannula inserted into the thoracic duct ⁴².

A 2017 case report noted the addition of octreotide to sirolimus therapy reduced chylous effusion in a woman with lymphangioleimyomatosis who developed refractory chylothorax and chylous ascites during sirolimus therapy ⁴³.

Postsurgical chylous ascites usually resolves with supportive therapy. Early reoperation is indicated when the site of leakage is apparent and if the patient is a good operative candidate ⁴⁴. Case reports have described the laparoscopic treatment of chylous leaks, using suture ligation and fibrin glue to control the leak ⁴⁵. In a separate report, fibrin glue applied to absorbable mesh was useful in patients with large areas of diffuse lymphatic leakage ⁴⁶. Another report described the treatment of chylous ascites after laparoscopic Nissen fundoplication with percutaneous injection of tissue glue (ie, N -butyl-cyanoacrylate mixed with ethiodol) into the thoracic duct ⁴⁷.

Lymphangiography itself may play more than a diagnostic role in the management of lymphatic leaks ⁴⁸. Lymphangiography with lipiodol led to the resolution of lymphatic leakage in a small number of patients with postoperative chylous ascites ⁴⁹. Lipiodol has been used as an embolic agent in a variety of angiographic procedures. Furthermore, it has been postulated that leakage of lipiodol from the site of lymphatic vessel perforation may stimulate a local inflammatory reaction in the surrounding soft tissues. This, in turn, may lead to the closure of the leaks ⁵⁰.

The combination of lymphangiography and lymphatic embolization appears to be effective in the treatment of refractory chylous ascites. In a retrospective study of 31 patients with refractory chylous ascites, the investigators visualized the lymphatic leak in 17 (55%) of the 31 patients who underwent conventional lymphangiography and in 7 (78%) of 9 patients who underwent magnetic resonance lymphangiography. Eleven of the 17 patients whose leak was identified underwent embolization with N-butyl cyanoacrylate glue and/or coils, with 9 patients (82%) achieving resolution of the chylous ascites. There was a 52% overall rate of ascites resolution, with greater success when the leak site was identified ⁵¹.

Similar results were noted in a retrospective study (2016-2017) of three patients with previously unidentifiable leakage site or failed lymphatic embolization who underwent endolymphatic balloon-occluded retrograde abdominal lymphangiography (BORAL) and embolization (BORALE) for the diagnosis and treatment of chylous ascites ⁵². Technical success with pelvic lymphangiography and BORAL was achieved in all three patients, and BORAL was technically successful in the two patients it was attempted in. Resolution of the chylous ascites occurred in all the patients, with no minor/major complications reported ⁵². More investigation is needed.

Peritoneovenous shunting has been used successfully in small numbers of patients with chylous ascites ⁵³. However, shunt failure is common and the procedure may be fraught with complications.

Use of transjugular intrahepatic portosystemic shunts (TIPS) to successfully treat chylous ascites related to cirrhosis has been reported ⁵⁴.

Malignant chylous ascites requires specific therapy directed at the primary cause as well as supportive therapy. These therapies may include chemotherapy, radiation, and surgery. Laparotomy and ligation of the leaking lymphatics, resection of a leaking small bowel segment, and removal of an obstructing tumor all have been attempted with varying degrees of success. Transient success also has been achieved with peritoneovenous shunts.

Laparotomy should not be used in pediatric patients with chylous ascites unless the condition is unresponsive to conservative therapy and a lesion that can be corrected by surgery is apparent.

Chylous ascites prognosis

The prognosis in adult patients with chylous ascites is poor due to its association with malignancy and severe liver disease. However, pediatric patients and adult patients with postsurgical and posttraumatic chylous ascites have a favorable prognosis.

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