Chylous ascites in cirrhosis: a case report and review of the literature

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism

BACKGROUND

The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization.

AIM

To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA.

METHODS

This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions.

RESULTS

A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003].

CONCLUSION

Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.

Lymphatic dysfunction in advanced cirrhosis: Contextual perspective and clinical implications

The lymphatic system plays a very important role in body fluid homeostasis, adaptive immunity, and the transportation of lipid and waste products. In patients with liver cirrhosis, capillary filtration markedly increases, primarily due to a rise in hydrostatic pressure, leading to enhanced production of lymph. Initially, lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation. However, the lymphatic functions become compromised with the progression of cirrhosis and, consequently, the lymphatic compensatory mechanism gets overwhelmed, contributing to the development and eventual worsening of ascites and edema. Neurohormonal changes, low-grade chronic inflammation, and compounding effects of predisposing factors such as old age, obesity, and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis. Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia, which may rupture into the intestinal lumen, resulting in the loss of protein, chylomicrons, and lymphocyte, with many clinical consequences. Rarely, due to high pressure, the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites. Despite being highly significant, lymphatic dysfunctions in cirrhosis have largely been ignored; its mechanistic pathogenesis and clinical implications have not been studied in depth. No recommendation exists for the diagnostic evaluation and therapeutic strategies, with respect to lymphatic dysfunction in patients with cirrhosis. This article discusses the perspectives and clinical implications, and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.

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.

Chylous Ascites: A Rare Adverse Effect of Methimazole Treatment for Grave's Disease-A Case Report and Review of the Literature

A 40-year-old woman was admitted due to an urticarial rash that was attributed to recent onset of methimazole treatment for a diagnosis of Grave's disease. The patient had no prior significant medical history and used no medications, including over-the-counter or herbal medications. Her sister had Grave's disease. On admission, the patient received corticosteroids with improvement in her rash. On the second day of the hospitalization, the patient complained of abdominal discomfort. Abdominal ultrasound revealed a large amount of new onset ascites. Peritoneal tap yielded a milky fluid with high triglyceride level (12.2 mmol/L or 1080 mg/dL), consistent with chylous ascites. After discontinuation of the methimazole, the ascites disappeared. The patient later underwent therapeutic thyroidectomy, after which all features of thyrotoxicosis had improved.

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.

Spontaneous resolution of chylous ascites following delivery: a case report

Introduction

Chyloascites or chyloperitoneum, which can be caused by different factors, is a process of eruption of one or many lymphatic vessels spontaneously. Malignant processes, inflammation or trauma can cause a sudden burst in a lymphatic vessel which will lead to a collection of milky fluid in any space of the human body with the abdominal cavity being the most common location. Chyloperitoneum is rare during pregnancy and this case is the fifth described worldwide.

Case presentation

We describe a case of chyloascitis in a 27-year-old primigravida Middle Eastern woman, found coincidentally during cesarean section. Free fluid was found in the abdominal cavity with no source of trauma or masses. An abdominal drain remained in situ for six days. The milky fluid was sent for biochemical analysis and found to be positive for triglycerides. Her postoperative course was uneventful. A computed tomography scan of the abdomen and pelvis was negative for fluid collection, tumors or other lesions. While this is the fifth case of chylous ascitis associated with pregnancy, it is the second found to be spontaneous with no obvious cause described to date.

Conclusion

Chylous ascitis is not always associated with tumors, inflammation or trauma. It can, although rarely, be associated with pregnancy. The course of pregnancy is usually uncomplicated in the cases published to date. This fifth case serves as a reminder for obstetricians, when presented with similar findings, to consider chylous ascitis as one of the differential diagnoses. Early diagnosis and appropriate treatment is vital for improved outcomes for the mother and the fetus.

OK-432 therapy for chylous pleural effusion or ascites associated with lymphatic malformations

OK-432 therapy is effective for the treatment of macrocystic lymphatic malformations (LMs), but the optimal management of patients with microcystic LMs associated with large chylous pleural effusions or chylous ascites is not resolved. We performed thoracoscopic- or laparoscopic-guided injection of OK-432 for 2 patients with diffuse microcystic LMs accompanied by refractory chylous pleural effusion or chylous ascites. Both cases responded well to OK-432 therapy with improvement/resolution of fluid collections and associated symptoms. We recommend the use of OK-432 therapy as a promising treatment for microcystic LMs with functionally significant lymphatic fluid collections.

Successful treatment of chylous ascites secondary to sarcoidosis with methotrexate

A 39-year-old African American woman with sarcoidosis developed chylous ascites. Computed tomography (CT) scan showed extensive thoracic, mesenteric, and retroperitoneal lymphadenopathy. Initial therapy with corticosteroids was unsuccessful in managing ascites and she needed frequent large-volume paracentesis for symptomatic relief. Methotrexate was effective in treating the condition and the patient has remained symptom-free for > 2 years. Chylous ascites secondary to sarcoidosis is extremely rare and this is the first reported case of successful treatment with methotrexate.

Lymphomas and chylous ascites: review of the literature

Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.

Chylous ascites caused by portal vein thrombosis treated with octreotide

Chylous ascites is an uncommon entity with variable causes and rarely arises from portal vein thrombosis. This is a case report of chylous ascites caused by idiopathic portal vein thrombosis that was refractory to medical therapy and shunt surgery, which showed an impressive response to treatment with subcutaneous octreotide. We review the literature on chylous ascites with particular reference to the role of somatostatin analogs in the management of this rare condition.

Gross chylous ascites in cirrhosis with massive portal vein thrombosis: diagnostic value of lymphoscintigraphy. A case report and review of the literature

Chylous ascites is an uncommon condition, which could be due to various causes. We report a case of gross chylous ascites in a patient with cirrhosis and portal vein thrombosis. It is confirmed that gross chylous ascites in a patient with cirrhosis and portal vein thrombosis heralds an ominous prognosis for the patient. Results also demonstrate that common therapeutic interventions confer minimal benefit to the patient, whose survival may be limited to a few months. The use of lymphoscintigraphy as a convenient method for diagnostic exploration of the chylous ascites is emphasized, as it does not lead to complications or adverse effects, and can be readily repeated as needed.

Chylous Ascites Revisited - old Disease, new Management

Extravasation of chyle from the intestinal lymphatics into the peritoneal cavity results in chylous ascites, identified by its characteristic milky appearance. Chylous ascites is rare, but it has been suggested that its incidence may be increasing in the adult population. Successful management depends on identifying the underlying cause of the lymphatic disruption. The spectrum of causative pathologies seen in adult and paediatric practices are vastly different: congenital lymphatic problems predominate in the latter, while occult malignancy often causes adult chylous ascites. This review looks at the various aetiologies, diagnosis and the recent advances in the management of this condition. gynaecological malignancies, while in the paediatric population, both sexes are affected equally. It has been suggested that the incidence of chylous ascites may be increasing in line with higher incidence of malignant disease and complications of HIV infection. The reason for this may simply reflect increased reporting of the disorder, or it may be due to increasing diagnostic capability.

The majority of early reports of chylous ascites describe anecdotal cases, and there are very few series describing the causes and management of the condition. This again reflects the rarity of chylous ascites.

There is a need for a review of this rare cause of ascites to highlight changing aetiology and new therapeutic options.

A case of chylous ascites

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