Year : 2016 | Volume
: 27 | Issue : 2 | Page : 386--390
Successful management of chylous ascites: A report of two cases
Shaan E Alam1, Sunny M Kar2, Pran M Kar3,
1 Department of Student Affairs, University College of Medical Sciences, New Delhi, India
2 Department of Student Affairs, Lake Erie College of Osteopathic Medicine, Bradenton, USA
3 Department of Nephrology, Veterans Affairs Medical Center, Orlando, Florida, USA
Pran M Kar
Department of Nephrology, Veterans Affairs Medical Center, Orlando, Florida
Chylous ascites consists of the accumulation of chyle in the peritoneal cavity. Diagnosis is established by cytochemical analysis of the fluid revealing fat globules and high triglyceride content. The majority of cases are caused by pathology that interferes with abdominal retroperitoneal lymphatic drainage. We present two cases of postoperative chylous ascites, one following a bilateral nephrectomy, the other following orthotopic heart transplantation. Treatment is typically conservative with the aim to alleviate abdominal distension and reduce the flow of lymph into the mesenteric lymph nodes. Postsurgical chylous ascites has high cure rate with conservative therapy alone. Therapeutic paracentesis, diuretics, salt restriction, a high-protein, low-fat, mediumchain triglyceride diet, and parenteral nutrition are considered in chronic cases. The effects of longterm paracentesis on patients remains to be seen. In patients requiring renal replacement therapy, removal of chyle during peritoneal dialysis is often attempted.
|How to cite this article:|
Alam SE, Kar SM, Kar PM. Successful management of chylous ascites: A report of two cases.Saudi J Kidney Dis Transpl 2016;27:386-390
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Alam SE, Kar SM, Kar PM. Successful management of chylous ascites: A report of two cases. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Jun 15 ];27:386-390
Available from: https://www.sjkdt.org/text.asp?2016/27/2/386/178573
Chylous ascites consists of the accumulation of chyle in the peritoneal cavity. It is a rare, postoperative complication due to either a blockage of the lymphatic system or leakage that is secondary to inadvertent injury of the cisterna chyli or one of its major lumbar tributaries. It usually presents as abdominal distention and pain, the drainage of milky fluid from the surgical wound, or abdominal drain. Diagnosis is established by cytochemical analysis of the fluid and staining with Sudan III that reveals fat globules and high triglyceride content. We present two cases of postoperative chylous ascites, one following a bilateral nephrectomy for polycystic kidney disease, which successfully responds to conservative measures including total parenteral nutrition and octreotide; and other one following orthotopic heart transplantation in which dietary modification and total parenteral nutrition failed, thus requiring that the patient receive repeated paracentesis every two to three months.
A 42-year-old Filipino man presented with left flank pain, vomiting, and hematuria of 10 days' duration. He was a known case of polycystic kidney disease, diagnosed 15 years earlier. He had continued to have bouts of gross hematuria, progressive renal insufficiency, and anemia over the past 10 years, which was managed conservatively. He had also presented with severe hematuria with blood clots in the urine one week previously. He had a peritoneal dialysis catheter placed in the past in preparation for renal replacement therapy. Physical examination revealed left flank tenderness, left costovertebral angle tenderness, and bilateral pedal edema. The peritoneal catheter site was intact, clean, and without any surrounding erythema. His blood urea nitrogen (BUN) was 34.3 mmol/ L; creatinine was 871.6 μmol/L; and estimated glomerular filtration rate was 6 mL/min, which is suggestive of end-stage renal disease. Renal replacement therapy was initiated with the tunneled catheter. A computed tomography (CT) of the abdomen and pelvis revealed that both kidneys had an enlarged appearance with numerous cysts consistent with polycystic disease, areas of increased density suggestive of hemorrhagic cysts and multiple calculi in the left kidney without collecting system dilatation and no mention of ureteral clots. The patient then underwent a bilateral nephrectomy for unrelenting pain in his kidneys from repeated episodes of gross hematuria and renal colic from calculi. He experienced some pain in the abdomen postoperatively. This was presumed to be due to incisional site pain, and a CT was done that showed bilateral fluid collection in the abdomen, which was assumed to be postoperative collection with some gas in the retroperitoneum. Considering these findings to be due to postoperative hematoma and possibility of reabsorption of air after the recent bilateral nephrectomy, aspiration of the collected fluid in the retroperitoneum was not done. He was started on hemodialysis through a temporary tunneled catheter. On account of the patient's improving general condition, he was discharged on antibiotics as needed, and a repeat CT scan was advised in one week.
On the 10 th day, postoperatively, he presented with complaints of nausea, vomiting, anorexia, and abdominal pain. He was not able to tolerate an oral diet well, his appetite was markedly reduced, and he continued to have the abdominal pain that he had had at the time of discharge, but now the abdominal pain was present more often in a lying down position, and it became aggravated after meals. Upon examination, he had bilateral pedal edema and ascites fluid in the abdomen; the incision site was clean, dry and intact with no redness or swelling, but mild tenderness was present around it. At this time, his nausea and vomiting was presumed to be medication-related or due to his gastritis. A gastrointestinal endoscopy was performed to rule out a gastrointestinal cause of nausea and vomiting. Uremia as the cause of symptoms was ruled out as his BUN was <30 mg/dL. In order to eliminate any intra-abdominal abnormality including hematoma, peritonitis or other sources of infection, a CT scan of the abdomen was advised without any contrast, and a peritoneal fluid analysis and a blood culture were performed. The CT scan revealed fluid collection in the bilateral renal fossa; the fluid was then drained with a peritoneal dialysis catheter and sent for culture. The peritoneal fluid as well as the blood culture revealed no significant growth. He stated that his symptoms of nausea, vomiting, abdominal pain, and anorexia improved after drainage of the ascites fluid. The fluid was cream-milk colored, and in addition, the triglyceride level in the ascites fluid was 156.9 mmol/L and staining with Sudan III revealed fat globules. The fluid was confirmed to be chylous and diagnosis of postoperative chylous ascites was reached, which was more likely due to injury to the lymphatic duct or cysterna chyli intraoperatively during the bilateral nephrectomy operation. The patient received conservative management. A low-fat diet was recommended along with mostly medium-chain triglyceride supplementation and a high-protein diet. He was advised not to drain the chylous fluid unless symptoms flared up in order to avoid malnutrition from enormous calorie loss.
Seven days later, the patient presented with unmanageable pain and an inability to tolerate an oral diet, as its intake was causing a rapid increase in the ascites fluid volume. This required daily drainage of 1-3 L of peritoneal fluid, which eventually resulted in his losing weight due to malnutrition. The patient reported nausea with occasional vomiting and abdominal pain after eating, which led to his decreased food intake, and which further aggravated his malnutrition. A failure to improve the patient's condition through dietary modification compelled the adoption of total parenteral nutrition and continuing treatment with statins and octreotide. The abdominal pain got significantly improved; the ascites build-up was resolved with repeated paracentesis, and the patient experienced relief from nausea and vomiting and an improved appetite. Renal replacement therapy in the form of hemodialysis was continued three times a week until he received a renal transplant.
A 70-year-old male underwent cardiac transplantation for ischemic cardiomyopathy 22 years ago, in the year 1990. The postoperative period was uneventful, and the patient maintained good cardiac function afterward. The patient was on cyclosporine. Subsequently, he developed chronic kidney disease and progressed to end-stage renal disease requiring renal replacement therapy in the form of hemodialysis. He was worked up for a possible transplant and was put on an active renal transplant list. In 2002, he presented with a distended abdomen, abdominal pain, nausea, and vomiting. A liver biopsy and transjugular portal pressure were reviewed, and the results were normal. The peritoneal fluid was examined and it was noted to be milky-white in color, to have a high triglycerides level, and to be Sudan-IIIpositive. The diagnosis of postoperative chylous ascites was made with a suspicion of ligation of the lymphatic duct at the time of heart transplantation in 1990 and destruction of collaterals at the time that the cholecystectomy was performed in 2000. The patient was taken off the transplant list until the ascites was resolved in the view of his nutritional state. The patient was put on a diet with medium-chain triglycerides and total parenteral nutrition along with repeated paracentesis of 6-7 L of chylous fluid every two to three months, but the patient failed to resolve and continued to require repeated paracentesis every two to three months.
Our first case of chylous ascites is unusual because the patient presented multiple times to emergency rooms with symptoms of nausea, vomiting, anorexia, and abdominal pain after nephrectomy, and the diagnosis of chylous peritonitis was not entertained until the last presentation, since physicians had not previously considered chylous ascites as a possible differential diagnosis.
Other etiologies of chylous ascites include congenital causes, infective peritonitis (HIV, tuberculosis, and spontaneous bacterial), neoplasm (Wilms' tumor, renal cell carcinoma, and carcinoid tumor), traumatic abdominal injury, and postsurgical complications. A large majority of cases are caused by diseases that interfere with abdominal retroperitoneal lymphatic drainage. Abdominal aortic aneurysm repair and retroperitoneal lymph node dissection are the most common surgical procedures that cause chylous ascites. In one study, 7% (n = 329) of patients with testicular cancer who underwent postchemotherapy retroperitoneal lymph node dis-section developed chylous ascites. ,
Chylous ascites can present acutely or chronically. Chronic chylous ascites can present with progressive and painless abdominal distention and respiratory difficulties secondary to diaphragmatic splinting. Anorexia, weakness, malaise, weight loss, diarrhea, malnutrition, early satiety, fevers, night sweats, and abdominal pain are very common constitutional presenting symptoms. Symptoms of acute chylous ascites are severe abdominal pain along with anorexia, nausea, and vomiting. A high-fat meal is a common precipitant in the development of symptoms. The chylous fluid tends to accumulate in the right paracolic gutter, mimicking the symptoms of acute appendicitis. Individuals with the abovementioned surgeries may present postoperatively with an increase in abdominal girth, weight gain, dyspnea, nausea, vomiting, wound infection, or leakage of chylous fluid through the suture line. 
Diagnosis is confirmed by abdominal paracentesis. The milky-white aspirate stains positive for fat with Sudan III dye. Cytology usually shows lymphocytes. Triglyceride levels are high, about two to eight times higher than of plasma. Protein content is greater than 3 g/dL. Serum albumin and lymphocyte levels are low in the blood. Anemia is secondary to protein loss and malnutrition. A lymphangiogram is not cost effective. A lymphoscintigraphy, with 99 technetium antimony sulfide colloid with human albumin or dextran, can pinpoint lymphatic leaks. However, a CT scan is the imaging procedure of choice and reveals intraand extraperitoneal fluid collection. A patho-gnomonic feature of chylous ascites on a CT scan is "fat fluid level." 
Treatment is conservative and the aim is to alleviate abdominal distension and reduce the flow of lymph into the mesenteric lymph nodes. Therapeutic paracentesis, diuretics, salt restriction, a high-protein, low-fat, medium-chain triglyceride diet, and parenteral nutrition are considered in chronic cases. The rationale for using medium-chain triglyceride is that they bypass lymphatic channels and enter directly into portal venous blood through the lymphatics of the bowel. The use of total parenteral nutrition should be considered as it helps to decrease the production of lymph and allows the bowel to rest. Somatostatin decreases the intestinal absorption of fats, lowers triglyceride concentration in the thoracic duct, and decreases lymph flow by decreasing splanchnic blood flow. Etilefrine, a sympathomimetic drug which acts by contracting the smooth muscles of the thoracic duct and thereby decreasing the flow of chyle can also be used.
Surgical intervention is needed if conservative therapy fails for several weeks, which includes direct ligation of the disrupted lymph channel or insertion of a peritoneal venous shunt. However, it is difficult to identify where the leak is. The prognosis for nonsurgical ascites is poorer because of underlying causes. Postsurgical chylous ascites has a 92.3% cure rate with only conservative therapy. 
Our patients raised our awareness of other causes of abdominal pain that need to be addressed among a myriad of differential diagnoses that need to be considered when seeing patients with this type of clinical presentation. The use of repeated abdominal paracentesis for the cardiac transplant patient with end-stage renal disease raises questions about using peritoneal dialysis as the modality of renal replacement therapy in this subgroup of patients. Moreover, we are left to delineate the direct consequences of chyle in the peritoneal cavity; both with regards to the impaired quality of dialysis across a compromised peritoneal membrane, as well as the anticipated malnutrition that accompanies such an inflammatory state. While removal of chyle during dialysis results in immunosuppression and malnutrition due to loss of lymphocytes and fats, respectively, these consequences do not justify a change in the modality of dialysis. Furthermore, with resolution of chylous ascites, these temporary discrepancies in both nutritional and immunologic status resolved concomitantly, carrying no documented long-term sequelae. , Studies looking at chyle causing inadequate dialysis in patients on peritoneal dialysis who are taking immunosuppressants have shown no such effect or increased risk. However, it has also been reported that peritoneal dialysis does pose a serious risk of peritonitis in immunocompromised patients and therefore should not be used as an initial modality of choice in this group. 
Conflict of interest: None declared.
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