Chylous Ascites

Chylous Ascites

Juan D. Rico, MD

Table of Contents

Background
Presentation and Diagnosis
Treatment

Background

Chyle: A Milky Fluid Made of Lymph and Emulsified Fats/Fatty Acids Formed in the Small Intestine During Digestion and Processed Through Lymphatic Vessels

Etiology

  • Caused by Lymphatic Obstruction or Damage
  • Malignancy (Lymphoma #1) – The Most Common Cause in Developed Countries
  • Cirrhosis
  • Infectious (Filariasis #1, Tuberculosis) – The Most Common Cause in the Developing World
  • Trauma
  • Iatrogenic Lymphatic Injury During Abdominal Surgery
  • Congenital Lymphatic Abnormalities – The Most Common Cause in Pediatrics
  • Right Heart Failure
  • Nephrotic Syndrome

Chylous Fluid Drained from the Abdomen 1

Presentation and Diagnosis

Presentation

  • Progressive and Painless Abdominal Distention
    • Generally Progresses Over Weeks-Months
    • May Be Associated with Nonspecific Abdominal Pain
  • Weight Gain or Weight Loss
  • Diarrhea
  • Nausea and Vomiting
  • Dyspnea
  • Night Sweats
  • Malnutrition
  • Electrolyte Imbalance
  • Dehydration

The Diagnosis is Uncommon and Rarely Considered Before a Paracentesis Has Been Performed

Diagnosis

  • Diagnosis is Achieved by Paracentesis – Triglycerides ≥ 110 mg/dL (Generally Above 200 mg/dL)
  • Imaging Can Assist in Evaluation for Abdominal Lymph Nodes and Dilated Lymphatics
    • CT/MRI
    • Lymphoscintigraphy
    • Lymphangiography (LAG) – The Gold Standard in Defining Obstruction

Treatment

The Primary Treatment Should Be Management of the Underlying Cause When Possible

Medical Management Alone is Effective for the Majority of Postoperative Chylous Ascites

Dietary Modifications – The Primary Approach to Ascites Reduction 

  • High Protein
  • Low Fat
  • Supplement Medium-Chain Triglycerides (MCT) – Reduce Production and Flow of Chyle
    • Long-Chain Triglycerides (LCT) Absorb into Lymphatics
    • Medium-Chain Triglycerides (MCT) Absorb Directly into Portal System
    • *Contraindicated in Decompensated Cirrhosis – Can Cause Narcosis and Coma

Consider Total Paracentesis if Large and Symptomatic – Repeat as Needed

Options if Refractory to Medical Managements

  • Intranodal Lymphangiography (INL) with Lymphatic Embolization
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS) if Cirrhotic
  • Laparotomy with Ligation of Leaking Lymphatics

References

  1. Shaik IH, Gonzalez-Ibarra F, Khan R, Shah S, Syed AK, Lintz D. Chylous Ascites in a Patient with HIV/AIDS: A Late Complication of Mycobacterium avium Complex-Immune Reconstitution Inflammatory Syndrome. Case Rep Infect Dis. 2014;2014:268527. (License: CC BY-3.0)