Chylous ascites
Overview
A rare disorder involving obstruction of the drainage of the abdominal lymph glands which results in abdominal accumulation of milky white fluid
Symptoms
* Abdominal distention * Milky white fluid in intraperitoneal area
Causes
Hepatic, resulting in portal hypertension –Hepatic cirrhosis: Extrahepatic biliary atresia, ?-1-antitrypsin deficiency, galactosemia, tyrosinemia –Portal vein thrombosis –Cavernous transformation: Catheterization, dehydration, clotting disorder, omphalitis –Budd-Chiari syndrome, due to neoplasm, collagen disease, hypercoagulopathy, OCP –Arteriovenous fistula –Fulminant hepatic failure (drugs, virus) –Congenital hepatic fibrosis –Lysosomal storage diseases (e.g., Gaucher) * Bile ascites (bile peritonitis): Spontaneous rupture of the common bile duct * Renal –Nephrotic syndrome –Urinary ascites (due to bladder rupture) –Obstructive uropathy: Congenital ascites may be seen with bilateral hydronephrosis * Peritoneal dialysis * Cardiac –Congestive heart failure –Chronic constrictive pericarditis –Inferior vena cava web –Erythroblastosis fetalis * Peritonitis –Tuberculous peritonitis –Schistosomiasis (Mansoni) –Tularemia –Abscess * Gastrointestinal disorders –Infarcted bowel –Bowel perforation –Pancreatitis, ruptured pancreatic duct –Protein-losing gastroenteropathy * Chylous ascites –Collection of lymph within the abdominal cavity; secondary to lymphatic obstruction from trauma, surgery, tumor, tuberculosis, or filariasis * Gynecologic –Ovarian tumors, cyst torsion or rupture * Malignancy –Leukemia, lymphoma, neuroblastoma * Systemic lupus erythromatosus * Ventriculoperitoneal shunt * Hypothyroidism
Treatment
* Treatment is directed at underlying cause * Bed rest, fluid, sodium restriction is the first line * Diuretics: Careful use in selected cases * Chylous ascites –High-protein, low-fat diet supplemented with medium-chain triglycerides –Parenteral nutrition may be needed to decrease lymph flow and supplement nutrition –Laparotomy may be indicated for failed dietary management, to seal leak site * Surgical intervention: Bile or urine ascites * Therapeutic paracentesis: May be repeated to relieve respiratory distress or impending umbilical rupture * Portacaval shunt or a peritoneovenous shunt (LeVeen) for intractable ascites –Shunt between peritoneal cavity and superior vena cava * Transjugular intrahepatic portosystemic shunt (TIPSS) for cirrhosis while awaiting transplantation