Use of orlistat (xenical) to treat chylous ascites

Chyloperitoneum After Penetrating Abdominal Trauma: A Report of a Rare Case

The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition.

Chylous Ascites Related to Radiotherapy in a Patient With Gastric Cancer

Chylous ascites is an uncommon complication seen in patients who have received radiotherapy to the abdomen. However, the morbidity caused by peritoneal ascites makes this an important complication to be considered when giving abdominal radiation to oncology patients. We present the case of a 58-year-old woman with gastric adenocarcinoma, who consulted for recurrent ascites after receiving abdominal radiotherapy as an adjuvant treatment to surgery. Different tests were carried out to evaluate the cause. Malignant abdominal relapse and infection were ruled out. Paracentesis evidenced swallowed fluid, therefore, the possibility of chylous ascites due to radiotherapy was considered. Intrathoracic, abdominal, and pelvic lymphangiography was performed with Lipiodol and the absence of cisterna chyli was confirmed as the cause of refractory ascites. After the diagnosis, the patient went under aggressive in-hospital nutritional support treatment, with clinico-radiological response.

Chylothorax and chylous ascites: Overview, management, and nutrition

Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.

Acute Chylous Ascites Status Post Median Arcuate Ligament Syndrome Decompression: A Unique Case Report and Literature Review

Chylous ascites (CA) are a rare finding of triglyceride-rich peritoneal fluid within the abdominal cavity. Malignancy, cirrhosis, and trauma after abdominal surgery are the leading causes of CA in adults. Currently, there are no published guidelines on the management of CA. This report describes a case of an 18-year-old female presenting with abdominal pain and distention following median arcuate ligament syndrome (MALS) decompression. A computed tomography (CT) of the abdomen and pelvis showed large-volume ascites with normal hepatic morphology. Paracentesis and ascitic fluid studies were positive for milky fluid rich in triglyceride. Her recent history of MALS decompression revealed the cause of her acute CA to be a postoperative complication from her abdominal surgery. This case highlights the diverse etiology of ascites and the importance of a careful history and physical examination when evaluating adults with ascites.

Chylous Ascites Secondary to Retroperitoneal Para-Aortic Lymphadenectomy: A Case Report

Chylous ascites is caused by an accumulation of lymphatic fluid in the peritoneal cavity secondary to a rupture or obstruction of the abdominal lymphatic ducts. It has a milky appearance and is rich in triglycerides. The most frequent etiologies are neoplasms, liver cirrhosis, and ruptured lymphatic vessels after abdominal surgery. Clinically, it manifests as abdominal distention and increased abdominal girth. The presence of triglycerides in ascites fluid is the most useful diagnostic criterion. Treatment consists of a high-protein diet with fat restriction and medium-chain triglyceride supplements. Surgery is reserved for refractory cases. We present the case of a 66-year-old patient with a diagnosis of chylous ascites secondary to retroperitoneal lymphadenectomy.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction. The underlying etiologies for CA have been classified as traumatic, congenital, infectious, neoplastic, postoperative, cirrhotic or cardiogenic. Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries, in this article we have attempted to reclassify CA based on portal and non-portal etiologies. The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of >200 mg/dL. The management consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Some studies have also supported the use of agents such as orlistat, somatostatin, octreotide and etilefrine. Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt (commonly known as TIPS), peritoneal shunt, angiography with embolization of a leaking vessel, and laparotomy remain as treatment options for cases refractory to medical management.

Review article: the diagnostic approach and current management of chylous ascites

BACKGROUND

Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance.

AIM

To review the current diagnostic approach and management of chylous ascites.

METHODS

A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included.

RESULTS

Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support.

CONCLUSIONS

Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.

A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature

OBJECTIVES

Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy.

MATERILAS AND METHODS

In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described.

RESULTS

Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition.

CONCLUSIONS

Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature

Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.

Management of high-output chylous ascites after D2-lymphadenectomy in patients with gastric cancer: a multi-center study

BACKGROUND

This study aimed to propose treatment strategies for high-output chylous ascites (CA) developed after gastric cancer surgery.

METHODS

The data of patients with CA after gastric cancer surgery in three high volume Training and Research Hospitals between 2005 and 2015 were retrospectively evaluated.

RESULTS

Nine patients out of 436 gastrectomies were detected with CA. The mean amount of daily fistula output was 939 mL. Treatment consisted of cessation of oral feeding, total parenteral nutrition (TPN), somatostatin analogs administration, clamping and/or removal of the drainage tube, diuretic administration and diet therapy with medium-chain triglycerides (MCTs) alone or in combination. The mean fistula closure time and length of hospital stay were 23 and 24 days respectively. Hemopneumothorax developed during right subclavian vein catheterisation for TPN implementation in one patient. There was no mortality.

CONCLUSIONS

Combined cessation of oral feeding and TPN are usually used for treatment of CA as first-line treatment. However, TPN is no harmless. Although our data are limited they do allow us to conclude that diet with MCT's may use for medical treatment of CA as first-line.

A Large Pleural Effusion following Abdominal Aortic Surgery

Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion.

Chylous Ascites: Evaluation and Management

Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.

Chylous ascites

Context:

Chylous ascites is the accumulation of milky chyle in the peritoneal cavity. Chylous ascites has been reported after surgeries like abdominal aortic aneurysm repair, radical gastrectomy, duodenectomy, nephrectomy and Wilm's tumor resection. Our literature search did not reveal any reports of chylous ascites after a gastric ulcer resection. We report about an elderly woman with a rare complication of chylous ascites after an emergent surgery for a perforated gastric ulcer.

Case Report:

A 70-year-old woman developed sudden respiratory distress on 5^th post-operative day after an elective C3-C7 cervical discectomy and fusion. Her past medical history was significant for cervical spondylosis. The Computed Tomography (CT) scan of the chest revealed air under the diaphragm suspicious for hollow viscus perforation. She underwent an emergent surgery for drainage of hematoma in the neck along with an emergent laparotomy to repair a large perforated gastric ulcer distal to the gastro-esophageal junction. The patient had worsening of abdominal distention on 4^th post-operative day. The CT scan of abdomen showed fluid collection in the abdomen. The abdominal drain revealed large amount of serous milky fluid at the rate of 1500 ml per day. The fluid analysis showed that the triglyceride level was 170 mg/dl and cholesterol level was 15 mg/dl. The fluid cultures did not grow any organism. She responded to treatment with octreotide and a diet of medium chain triglyceride oil.

Conclusion:

Any obstruction or damage to the lymphatic channels results in chylous ascites. Lymphomas, metastatic malignancies, and abdominal surgeries commonly cause chylous ascites. Ascitic fluid triglyceride level greater than 110 mg/dl is diagnostic of chylous ascites. Chylous ascites is a rare complication of a peptic ulcer resection which can be managed effectively with octreotide.

Chylous ascites complicating elective abdominal aortic aneurysm repair: case report and review of treatment options

INTRODUCTION

Chylous ascitis is a rare complication of abdominal aortic aneurysm (AAA) surgery with only 38 cases reported since the early 70s. Due to their anatomical relation with the abdominal aorta, cisterna chyli injury is more common following open AAA repairs when compared to other surgeries; 81% of all postsurgical chylous ascites reported.

CASE PRESENTATION

We present a case of severe chylous ascitis following elective AAA repair in a 76-year-old caucasian male who gradually developed abdominal distension following discharge. A conservative approach was followed by a peritoneovenous shunt insertion, but this had no clinical benefit. The site of chyle leak was identified and ligated at relaparatomy to eventually resolve his ascitis.

CONCLUSION

Many reports in literature demonstrate successful conservative measures and highlight the importance of nutritional status in the course of persistent postoperative chylous ascitis. In our experience, complete resolution only came after relaparatomy and repair of leaking lymphatics.

Chylous ascites secondary to giant liver hemangioma

Chylous ascites is rare in clinical practice. It is characterized by milky-appearing peritoneal fluid with a triglycerides concentration of >1.25 mmol/l (110 mg/dl). Its pathophysiology is related to a disruption in the normal lymphatic flow. It is more common after trauma (including post surgery), neoplasia or atypical infections such as tuberculosis or filariasis. Other rare medical causes have been reported. The treatment is supportive and focused on correction of the underlying pathology. We report here the first case of chylous ascites caused by giant liver hemangioma and discuss the management of this condition.

[Octreotide treatment for postoperative chylous ascites in an adult]

Chylous ascites is infequent after abdominal surgery. We describe the case of a 43-year-old man with portal cavernomatosis who underwent surgery to insert a splenorenal shunt, which was not placed due to the absence of signs of portal hypertension. On postoperative day 20, the patient developed abdominal distension and mild dyspnea and was diagnosed with chylous ascites, which was related to the surgery. The patient was initially treated with diet and diuretics, with no clinical response, and consequently octreotide therapy was started. Four days later, the ascites was almost resolved and an ultrasound scan at 4 months showed its complete disappearance. This article demonstrates the effectiveness of octreotide in the treatment of postsurgical chylous ascites.

Acute chylous peritonitis mimicking ovarian torsion in a patient with advanced gastric carcinoma

The extravasation of chyle into the peritoneal space usually does not accompany an abrupt onset of abdominal pain with symptoms and signs of peritonitis. The rarity of this condition fails to reach preoperative diagnosis prior to laparotomy. Here, we introduce a case of chylous ascites that presented with acute abdominal pain mimicking peritonitis caused by ovarian torsion in a 41-yr-old female patient with advanced gastric carcinoma. An emergency exploratory laparotomy was performed but revealed no evidence of ovarian torsion. Only chylous ascites was discovered in the operative field. She underwent a complete abdominal hysterectomy and salphingo-oophorectomy. Only saline irrigation and suction-up were performed for the chylous ascites. The postoperative course was uneventful. Her bowel movement was restored within 1 week. She was allowed only a fat-free diet, and no evidence of re-occurrence of ascites was noted on clinical observation. She now remains under consideration for additional chemotherapy.

Immunological research using RNA interference technology

RNA interference (RNAi) is a potent method of gene silencing that has developed rapidly over the past few years as a result of its extensive importance in the study of genetics, molecular biology and physiology. RNAi technology has also recently yielded significant insight into the innate and adaptive immune systems by helping to elucidate numerous mechanisms that regulate the development, activation and function of cells that mediate immunity. In addition, because of its ability to suppress gene expression effectively, this technique may be used to regulate the immune response for clinical purposes. Nonetheless, before RNAi can be successfully administered into human patients as a medical treatment, it is necessary to overcome several major limitations of this technology, such as inefficient in vivo delivery, incomplete silencing of target genes, non-specific immune responses, and off-target effects. As novel developments and discoveries in molecular biology swiftly continue to unfold, it is likely that RNAi may soon translate into a potent form of in vivo gene silencing with profound applications to vaccination and immunotherapy. In the present review, we examine the current progress of immunological studies employing RNAi and discuss the prospects for the implementation of this technique in the clinical arena.