Chylous ascites secondary to pancreatitis: management of an uncommon entity using parenteral nutrition and octreotide

Ascites in Acute Pancreatitis: Clinical Implications and Management

Clinically significant ascites in acute pancreatitis (AP) is rarely encountered and is a result of multifactorial pathogenesis. Early reactionary ascites in AP usually does not require any treatment and resolves spontaneously in majority of patients. A diagnostic analysis should be performed in case of ascites developing in the latter stages with increasing pain or worsening organ failure. Low serum albumin-ascites gradient ascites with amylase > 1000 U/l is highly suggestive of pancreatic ascites that is usually associated with duct disruption. A combination of nasojejunal feeding, subcutaneous octreotide, endoscopic drainage and rarely, surgery are employed in managing this difficult to treat condition. There is a need of further studies to better understand the clinical role of ascites as well as contribution of other factors like hypoalbuminemia and portal hypertension to its development in AP.

Lipoprotein profile of pleural and peritoneal transudates in dogs and cats

BACKGROUND

Current diagnostic evaluation of transudative effusions rarely aids in identifying an underlying etiology. Lipoproteins in the fluid might reflect the site or nature of vessel involvement.

OBJECTIVES

Improve the classification and diagnostic utility of pleural and peritoneal transudates in dogs and cats by investigating lipoprotein patterns in effusions. Compare these patterns with other peritonaeal and pleural fluid variables and underlying diseases.

ANIMALS

Samples of transudates and serum from 18 cats and 37 dogs with transudative effusion (total nucleated cell count [TNCC] <5000 cells/μL) were analyzed.

METHODS

Lipoprotein fractions, triglyceride, and cholesterol (CHO) concentrations were prospectively determined in paired fluid and serum samples. Standard fluid measurements were retrospectively collected.

RESULTS

Two distinct fluid lipoprotein patterns were noted. Fluids rich in VLDL+IDL were associated with chronic kidney disease, acquired portosystemic shunts or protein-losing enteropathy (group I). Fluids rich in denser lipoproteins were associated with underlying heart disease, caudal vena cava syndrome or intracavitary neoplasia (group II). Group I and group II also had significant differences between fluid concentrations of CHO (x̄ = 8 vs 110 mg/dL) and TP (x̄ = 0.6 vs 3.8 g/dL), respectively. Five peritoneal transudates were triglyceride-rich (>100 mg/dL) and associated with pancreatitis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Protein-poor (TP <1.5 g/dL) and protein-rich (TP >2.5 g/dL) transudates were associated with distinct lipoprotein patterns and specific groups of disease. Effusions secondary to pancreatitis might be transudative and rich in triglycerides.

[Spontaneous diffuse chylous peritonitis during pregnancy]

Spontaneous chylous peritonitis during pregnancy is a rare disease. Only a few publications are currently devoted to this problem. The authors reported successful treatment of a patient with spontaneous chylous peritonitis in the first trimester of pregnancy. Moreover, etiology, epidemiology, pathophysiology, diagnosis and treatment of patients with spontaneous chylous peritonitis and chiloperitoneum are analyzed. The authors consider laparoscopy as a safe and efficient method of treatment of patients with spontaneous chylous peritonitis including pregnant women.

An Unusual Combination of Three Rare Complications: Pleuro-Pancreatic Fistula, Chylous Ascites, and Renal Vein Thrombosis, in a Case of Acute Severe Pancreatitis

Background  Acute pancreatitis is fraught with a variety of complications, which account for the mortality associated. Our case had a fulminant course, with three rare, near-fatal complications and was successfully managed conservatively. Pleural effusion due to pleuro-pancreatic fistula is uncommon, seen in only 1% cases, of which right-sided effusions are rarer still. Management modalities include conservative, endoscopic, and surgical options. Chylous ascites is an extremely rare complication of pancreatitis and is managed with high protein, low lipid diet, restricted to medium-chain triglycerides (MCTs). Extra-splanchnic venous thrombosis is uncommon in pancreatitis, and isolated renal vein thrombosis is very rare.

Case Presentation  A 34-year-old, chronic alcoholic male, presented to the outpatient department (OPD) in a state of shock and respiratory distress. Chest radiograph showed massive right-sided pleural effusion. The pleural fluid was hemorrhagic with markedly elevated amylase levels, and contrast-enhanced computed tomography (CECT) confirmed the presence of a right-sided pleuro-pancreatic fistula. Left renal vein thrombosis was also noted. The patient improved with chest drain, intravenous (IV) octreotide, and anticoagulants. Subsequently, he developed hemorrhagic pancreatic ascites, which later turned chylous. This was managed with dietary modifications. The patient had a prolonged recovery but was finally discharged after 45 days.

Conclusion  It is a challenge managing the various complications of acute severe pancreatitis. We describe this case to emphasize maintaining a high sensitivity for timely diagnosis and appropriate addressal of all the complications for better patient outcomes.

Chylous ascites due to idiopathic chronic pancreatitis managed with endoscopic stenting

Chylous ascites is an uncommon clinical entity, which usually results from congenital or acquired abnormality in proper lymphatic flow. While the common causes are related to trauma, malignancy or tuberculosis, pancreatic disorders can occasionally result in chylous ascites. Sporadic cases of chylous ascites due to acute or chronic pancreatitis or surgery for pancreatitis have been reported. The usual management is with medium chain triglycerides (MCT), total parenteral nutrition and octreotide. We report a case of a young male with idiopathic chronic pancreatitis who presented with chylous ascites which did not respond to MCT based diet and octreotide. The patient improved with endoscopic pancreatic duct stenting.

Idiopathic chylous ascites in a patient with HIV infection: response to total parenteral nutrition and octreotide therapy

The authors describe a 47-year-old man infected with human immunodeficiency virus admitted for ascites and weight loss. Ascitic fluid analysis revealed chylous ascites (triglycerides 444 mg/dl) with negative microbiological tests. Neoplasia, cardiac disease and liver cirrhosis were excluded after an extensive diagnostic workout. Exploratory laparotomy with tissue sampling did not clarify ascites etiology. During hospital admission, patient status gradually deteriorated, severe malnutrition developed and ascites became refractory to diuretics. Total parenteral nutrition and octreotide therapy were started and maintained for 3 weeks with ascites resolution and no relapse after oral diet resumption. Chylous ascites is a rare entity with several causes that compromise intra-abdominal lymphatic drainage. This case illustrates the difficulty in establishing etiology in some patients and the effectiveness of total parenteral nutrition plus octreotide therapy in idiopathic chylous ascites in HIV-infected patients.

A Mnemonic for Pharmacists to Ensure Optimal Monitoring and Safety of Total Parenteral Nutrition: I AM FULL

Objective: To present a guideline-derived mnemonic that provides a systematic monitoring process to increase pharmacists’ confidence in total parenteral nutrition (TPN) monitoring and improve safety and efficacy of TPN use. Data Sources: The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines were reviewed. Additional resources included a literature search of PubMed (1980 to May 2016) using the search terms: total parenteral nutrition, mnemonic, indications, allergy, macronutrients, micronutrients, fluid, comorbidities, labs, peripheral line, and central line. Articles (English-language only) were evaluated for content, and additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language observational studies, review articles, meta-analyses, guidelines, and randomized trials assessing monitoring parameters of TPN were evaluated. Data Synthesis: The ASPEN guidelines were referenced to develop key components of the mnemonic. Review articles, observational trials, meta-analyses, and randomized trials were reviewed in cases where guidelines did not adequately address these components. Conclusions: A guideline-derived mnemonic was developed to systematically and safely manage TPN therapy. The mnemonic combines 7 essential components of TPN use and monitoring: Indications, Allergies, Macro/Micro nutrients, Fluid, Underlying comorbidities, Labs, and Line type.

Chyloperitoneum associated with idiopathic pancreatitis: case report and review of the literature

Acute chylous peritonitis is defined as the onset of acute abdomen findings due to abrupt chylous fluid accumulation in the peritoneal space. A correct diagnosis of this condition is seldom made preoperatively. The optimal management of true chylous pancreatitis depends upon the underlying etiology. Thorough lavage of the abdomen and adequate drainage has proven to be an excellent treatment modality for acute chylous peritonitis, since resolution of chylous ascites usually occurs within the next few days. However, conservative treatment may be appropriate in selected cases. We present a case report and a brief review of the literature.

Chyle leak following biliary pancreatitis

Chylous ascites is a rare clinical entity that historically has been accompanied by high mortality due to the association with malignancy. Here we present a case of chylous ascites as a complication of mild pancreatitis in a young woman. We review the literature of similar cases, which revealed four similar cases with a range of outcomes. Treatment options vary from dietary restriction of medium chain fatty acids, total parental nutrition, radiological intervention and surgery.

Early enteral nutrition with polymeric feeds was associated with chylous ascites in patients with severe acute pancreatitis

OBJECTIVE

Chylous ascites (CA) may be involved in the pathological process of severe acute pancreatitis (SAP), but the underlying mechanisms remain unknown. This study investigated the incidence of CA in patients with SAP and its relationship with enteral nutrition (EN).

METHODS

A retrospective review of 85 patients with SAP admitted to our hospital was performed. Patients starting EN within 72 hours after the onset of SAP were classified as the early EN (EEN) group, and others, as the later EN group. The incidences of CA and prognosis in the EEN and later EN groups were examined with nutrition preparation of polymeric formula or semielemental feed.

RESULTS

Thirteen (15.29%) of 85 patients were identified with CA. A higher incidence of CA was observed in EEN patients who received polymeric formula (9 of 33, P < 0.05). All patients with CA were successfully treated with a modified medium-chain triglyceride diet. Consequently, there were no differences in intensive care unit stay and in mortality rates in patients with or without CA.

CONCLUSIONS

There was a higher incidence of CA associated with early enteral feeding of polymeric formula in patients with SAP. Future studies are warranted to confirm our findings and evaluate better enteral feeding options to avoid CA.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis. The concept of transudate versus exudate, as determined by total protein measurements, is outdated and the use of serum-ascites albumin gradient as an indicator of portal hypertension is more accurate. Lactate dehydrogenase (LDH), vascular endothelial growth factor (VEGF), and other tumor markers can be helpful in distinguishing between malignant and benign conditions. Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease, and amylase level may indicate a diagnosis of pancreatitis. Given the specificity and sensitivity of laboratory results, accurate diagnosis should be based on both laboratory data and clinical judgment.

Chylous ascites as a consequence of idiopathic pancreatitis

Chylous ascites (chyloperitoneum) is a rare clinical condition, characterized by an accumulation of lymph fluid in the peritoneal cavity. Most commonly it is associated with abdominal malignancy (usually lymphoma). We present an unusual case of a woman who developed a persistent pseudocyst and recurrent chylous ascites following acute necrotizing pancreatitis.

Chronic Pancreatitis Associated with Chylous Ascites Simulating Liver Cirrhosis

Purpose. Ascites, esophageal varicose veins, and acute digestive bleeding are unusual in the clinical presentation of chronic pancreatitis; however, these symptoms are frequently observed in patients with liver cirrhosis. Moreover, it is unlikely to observe chylous ascites in both presentations. Method. We report a patient who presented with chronic pancreatitis with splenic vein thrombosis, necrosis of the pancreatic neck and tail, esophageal varicose veins with previous bleeding, and chylous ascites. After partial pancreatectomy, his treatment was based on low-fat oral diet with medium-chain triglycerides with remarkable resolution of the chylous ascites. After 3 years, he presented with decompensated chronic pancreatitis and underwent plexus alcoholization and biliary-enteric deviation with an unremarkable postoperative course. Conclusion. Ascites is rarely associated with chronic pancreatitis, and chylous ascites is even rarer. The treatment of atraumatic chylous ascites is based on resolution of the obstructive causes and should include drainage and a low-fat diet with medium-chain triglycerides.

[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 due to acute pancreatitis

We report a case of acute chylous ascites formation presenting as peritonitis (acute chylous peritonitis) in a patient suffering from acute pancreatitis due to hypertriglyceridemia and alcohol abuse. The development of chylous ascites is usually a chronic process mostly involving malignancy, trauma or surgery, and symptoms arise as a result of progressive abdominal distention. However, when accumulation of “chyle” occurs rapidly, the patient may present with signs of peritonitis. Preoperative diagnosis is difficult since the clinical picture usually suggests hollow organ perforation, appendicitis or visceral ischemia. Less than 100 cases of acute chylous peritonitis have been reported. Pancreatitis is a rare cause of chyloperitoneum and in almost all of the cases chylous ascites is discovered some days (or even weeks) after the onset of symptoms of pancreatitis. This is the second case in the literature where the patient presented with acute chylous peritonitis due to acute pancreatitis, and the presence of chyle within the abdominal cavity was discovered simultaneously with the establishment of the diagnosis of pancreatitis. The patient underwent an exploratory laparotomy for suspected perforated duodenal ulcer, since, due to hypertriglyceridemia, serum amylase values appeared within the normal range. Moreover, abdominal computed tomography imaging was not diagnostic for pancreatitis. Following abdominal lavage and drainage, the patient was successfully treated with total parenteral nutrition and octreotide.

Acute appendicitis together with chylous ascites: is it a coincidence?

Acute chylous ascites is a rarely seen clinical picture, therefore, examination findings are often confused with acute appendicitis. To the best of our knowledge, there is no publication to date showing the occurrence of them together. This study presents the treatment plan for a 25-year-old male patient with both acute chylous ascites and appendicitis. Surgical findings were retrocaecal appendicitis, evident lymphangiectasia in the proximal segment of jejunum, and approximately 3 lt of chylous fluid. An appendectomy was performed and drainage was applied. Low-fat total parenteral nutrition (TPN) and octreotide treatment were administered for 7 days postoperatively. We also present a general review of some studies on chylous ascites, which have been published in the English language medical literature since 1910.

Acute chylous ascites mimicking acute appendicitis in a patient with pancreatitis

We report a case of acute chylous peritonitis mimicking acute appendicitis in a man with acute on chronic pancreatitis. Pancreatitis, both acute and chronic, causing the development of acute chylous ascites and peritonitis has rarely been reported in the English literature. This is the fourth published case of acute chylous ascites mimicking acute appendicitis in the literature.

Chylous Ascites in a Patient with Inflammatory Myofibroblastic Tumor

Background

We present the case of a 64-year-old patient who presented to his primary care physician with fatigue, worsening shortness of breath, abdominal discomfort and a rapidly growing abdominal girth, although he had lost 5 kg of weight within 3 months. He had a history of untreated hypertension, compensated renal insufficiency and COPD. Despite weight loss and fatigue, the patient did not experience any other constitutional symptoms such as fever, night sweats or loss of appetite. Investigations: Physical examination, blood tests, CT scan of the abdomen, MRI scan of the abdomen, fine needle biopsy, excisional biopsy, Video Capsule Endoscopy, histology, PET scan. Diagnosis: Inflammatory myofibroblastic tumor, chylous ascites, chyloperitoneum. Management: Systemic chemotherapy, total parenteral nutrition and octreotide therapy.

Conclusion

We describe the case of a patient in whom two extremely rare phenomena are present in combination: the diagnosis of an inflammatory myofibroblastic tumor and chylous ascites. While the tumor could be stabilized by different regimens of chemotherapy, the chyloperitoneum was treated with parenteral nutrition and subcutaneous octreotide injections, which resulted in a significant reduction of the amount of chylous ascites drained during regular paracentesis.