A 56-year-old alcoholic patient presents with increased abdominal distention and pain and moderate shortness of breath. He claims that he had a routine paracentesis three weeks earlier that removed six liters of “fluid.”
Here is what you obtain after a diagnostic and therapeutic paracentesis. What is the likely diagnosis and treatment for this condition?
See p. 12.
Diagnosis: Chylous Ascites
Chyloperitoneum is a rare finding that develops from the extravasation of lymphatic fluid into the peritoneal cavity. Chyle is a milky substance consisting of emulsified fats and lymph fluid extracted from chyme by the lacteals during digestion and transported via the thoracic duct.
Extravasation chyle can be from injury (direct surgical trauma, post-radiation, pancreatitis [Case Rep Surg 2013;2013:763561]) or severe obstruction (mass effect from lymphoma or carcinoid tumor, right-sided heart failure with a dilated cardiomyopathy, or cirrhosis) and from rupture of the lymphatic channels, resulting in a lymphoperitoneal fistula. Increased hepatic and caval congestion is known to increase hepatic lymph production, which exacerbates the potential formation of chyloperitoneum. (J Am Coll Surg 2011;212:899; Surgery 2000;128:761; Am J Gastroenterol 1984;79:133.)
Infectious conditions causing mechanical obstruction or invasion including tuberculosis and filarial infections are more common etiologies in developing countries. (Arch Pediatr 2013;20:274; J Assoc Physicians India 1983;31:801.)
Patients with chyloperitoneum will present as typical cases with ascites, which may include the stigmata of liver disease, pleural effusions, lower extremity edema, a fluid wave, cachexia, temporal wasting, and hernias. Paracentesis is required to make a definitive diagnosis. Typically chyle appears as thick milky-white fluid, but laboratory testing to confirm significantly elevated triglyceride levels is needed to differentiate it from malignancy or infection. (Hepatology 1988;8:1104.) Abdominal radiological imaging may be helpful to identify the etiology of the chyloperitoneum if unknown. (Cardiovasc Intervent Radiol 2012;35:117.) It is not typically required emergently.
The evaluation of a patient with a confirmed chyloperitoneum should include identifying the underlying etiology. The incidence of chyloperitoneum is thought to be increasing because instrumentation procedures of the chest and abdominal cavities are on the rise. The most common reported etiology is invasion from metastatic intra-abdominal lesions. Congenital lymphatic malformations are the most commonly noted etiology in pediatric patients. (Ann Intern Med 1982;96:358.)
Treating chyloperitoneum begins with, if possible, addressing the underlying etiology. Otherwise, limited data are available to support other treatments. Typically, conservative therapy includes paracentesis, a low-fat, high-protein diet, and medium-chain triglyceride supplementation to reduce the production and flow of chyle. (Acta Paediatr 2010;99:1307; Br J Surg 1992;79:1145; J Clin Gastroenterol 1990;12:693.) Surgery may benefit patients with malignancy-related or post-operative complications or those with congenital malformations. (Surgery 2000;128:761.)
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