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Aetiology and treatment of chylous ascites
N L Browse1, N M Wilson, F Russo
1Department of Surgery, St Thomas' Hospital, London, UK.
Insights
Chylous ascites in 45 patients was reviewed, with primary lymphatic abnormalities in 35. Dietary management is effective for small bowel lymphatic leaks, while fistula closure offers success for retroperitoneal leakage.
Area of Science:
- Gastroenterology
- Pediatric Gastroenterology
- Vascular Medicine
Background:
- Chylous ascites is a rare condition characterized by the accumulation of chyle in the peritoneal cavity.
- It can be primary, due to lymphatic abnormalities, or secondary to other conditions like lymphoma.
- Understanding the mechanisms and effective treatments is crucial for patient management.
Purpose of the Study:
- To review a series of patients with chylous ascites.
- To identify the underlying mechanisms of ascites formation.
- To evaluate the effectiveness of different treatment modalities.
Main Methods:
- Retrospective review of 45 patients diagnosed with chylous ascites.
- Lymphangiography and intraoperative inspection were used to identify leakage sites.
- Analysis of patient demographics, lymphatic abnormalities, and treatment outcomes.
Main Results:
- The median age of presentation was 12 years, with 23 patients under 15.
- Primary lymphatic abnormalities were found in 35 patients; lymphoma was the most common secondary cause (6 patients).
- Two main leakage mechanisms: retroperitoneal megalymphatics (14 patients) and dilated small intestinal lymphatics (24 patients). Dietary manipulation was most effective for small bowel leaks; surgical fistula closure cured 7/12 patients.
Conclusions:
- Chylous ascites has diverse causes and mechanisms, often involving lymphatic abnormalities.
- Conservative dietary management is effective for small bowel lymphatic leakage.
- Surgical intervention, particularly fistula closure, can be successful for specific types of chylous ascites.
Abstract:
A series of 45 patients with chylous ascites has been reviewed. The age at presentation ranged from 1 to 80 (median 12) years; 23 patients were aged < or = 15 years. Thirty-five patients had an abnormality of the lymphatics (primary chylous ascites); in the remaining ten, the ascites was secondary to other conditions, principally non-Hodgkin's lymphoma (six patients). Two principal mechanisms of ascites formation were identified using lymphangiography and inspection at laparotomy: leakage from retroperitoneal megalymphatics, usually through a visible lymphoperitoneal fistula (14 patients); and leakage from dilated subserosal lymphatics of the small intestine, invariably associated with leaking lacteals causing protein-losing enteropathy (24 patients). Both sites of leakage were present in a further five patients. In the remaining two patients, chyle was leaking from normal mesenteric lymphatics, in one via a ruptured mesenteric lymph cyst and in the other from the site of a previous lymph node biopsy. Other associated lymphatic abnormalities were present in 36 patients, lymphoedema of the leg being the commonest (26 patients). All patients were initially treated conservatively with dietary manipulation; this was the most satisfactory treatment for those with leaking small bowel lymphatics. Surgery (fistula closure, bowel resection or insertion of a peritoneovenous shunt) was performed in 30 patients. Closure of a retroperitoneal fistula, when present, was the most successful operation, curing seven of the 12 patients so treated.