Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions.

OBJECTIVES: Lipoprotein electrophoresis is the gold standard for the detection of chylous ascites and pleural effusions. It is, however, not suitable as a front-line test and not widely available. Most clinicians must rely solely on the quantitative determination of lipids. The aim of this work was to establish lipid cut-off values for the presence of chylomicrons in pleural and peritoneal fluid. DESIGN AND METHODS: Triglyceride and cholesterol levels from 113 peritoneal and 154 pleural fluid samples investigated for chylomicrons via lipoprotein electrophoresis were considered. Receiver operating characteristic analyses were performed and cut-off levels determined. RESULTS: 54 peritoneal and 59 pleural fluid samples were positive for chylomicrons. In peritoneal fluid, triglycerides and triglycerides/cholesterol ratio exhibited areas under the curve (AUC) not significantly different from each other, but significantly larger than cholesterol alone. The AUC for triglycerides in pleural fluid was significantly larger than the AUCs for cholesterol and the triglycerides/cholesterol ratio. Triglyceride cut-offs with maximum Youden-Index, sensitivity >95%, and specificity >95% were calculated to be 187, 148, and 246mg/dl (2.13, 1.69, and 2.80mmol/l) for peritoneal fluid, and 240, 94, and 240mg/dl (2.74, 1.07, and 2.74mmol/l) for pleural fluid. CONCLUSIONS: Triglyceride levels are the best parameter to detect chylous body fluids when lipoprotein electrophoresis is not available. Single-point triglyceride cut-offs of 187 and 240mg/dl (2.13 and 2.74mmol/l) or alternatively equivocal ranges of 148-246 and 94-240mg/dl (1.69-2.80 and 1.07-2.74mmol/l) were established for peritoneal and pleural fluid, respectively.

Therapeutic Application of Percutaneous Peritoneovenous (Denver) Shunt in Treating Chylous Ascites in Cancer Patients.

PURPOSE: To evaluate the safety and efficacy of percutaneous peritoneovenous shunt (PPVS) placement in treating intractable chylous ascites (CA) in patients with cancer. MATERIALS AND METHODS: Data from 28 patients with refractory CA treated with PPVS from April 2001 to June 2015 were reviewed. Demographic characteristics, technical success, efficacy, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analysis was performed. RESULTS: Technical success was 100%, and ascites resolved or symptoms were relieved in 92.3% (26 of 28) of patients. In 13 (46%) patients with urologic malignancies, whose ascites had resulted from retroperitoneal lymph node dissection, the ascites resolved, resulting in shunt removal within 128 days ± 84. The shunt provided palliation of symptoms in 13 of the remaining 15 patients (87%) for a mean duration of 198 days ± 214. Serum albumin levels increased significantly (21.4%) after PPVS placement from a mean of 2.98 g/dL ± 0.64 before the procedure to 3.62 g/dL ± 0.83 (P < .001). The complication rate was 37%, including shunt malfunction/occlusion (22%), venous thrombosis (7%), and subclinical disseminated intravascular coagulopathy (DIC) (7%). Smaller venous limb size (11.5 F) and the presence of peritoneal tumor were associated with a higher rate of shunt malfunction (P < .05). No patient developed overt DIC. CONCLUSIONS: PPVS can safely and effectively treat CA in patients with cancer, resulting in significant improvement in serum albumin in addition to palliation of symptoms.

The role of vascular endothelial growth factor-D in diagnosis of lymphangioleiomyomatosis (LAM).

BACKGROUND: Definite diagnosis of lymphangioleiomyomatosis (LAM) depends on either transbronchial lung biopsy or video-assisted thoracic surgery, unless there is a history of chylothorax, kidney angiomyolipoma (AML), or tuberous sclerosis complex (TSC). Vascular endothelial growth factor-D (VEGF-D) was recently considered as a novel diagnostic marker for LAM. Herein, we evaluated diagnostic value of serum VEGF-D in LAM patients. METHODS: Serum samples were obtained from 78 cases of LAM (50 definite and 28 probable LAM based on European Respiratory Society guidelines), and 40 healthy female volunteers. VEGF-D was measured using enzyme-linked immunosorbant assay according to product instruction (R&D). RESULTS: Serum VEGF-D was significantly increased in definite LAM group, compared with that of health control (median: 3841.9 pg/mL vs 405.5 pg/mL respectively, p < 0.001). The optimal cut-off point for definite LAM diagnosis was 850.7 pg/mL. In probable LAM group, the majority of patients (92.9%) had serum VEGF-D level over 850.7 pg/mL. The serum levels of VEGF-D in LAM patients with pulmonary cystic lesions only were lower than that in patients with any of evidences of AML, chylous effusions, adenopathy, lymphangioleiomyomas, or TSC, but higher than that in the health control. In addition, VEGF-D levels were correlated with disease severity measured as LAM CT grade, and presentations of chylous effusions and/or lymphatic involvement (p < 0.05). CONCLUSION: Serum VEGF-D should be added to the current diagnosis algorithm to enhance definitive diagnosis for LAM.

[Postsurgical chylous ascites: case report and literature review]. / Tratamiento dietético de la ascitis quilosa postquirúrgica: caso clínico y revisión de la literatura.

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy.

The effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis.

Octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. Thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. Eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between January 2003 and May 2008. Octreotide was given to the six patients, while the remaining two were treated as a control. All patients had persistent peritoneal drainage with the quantity and quality of the drainage fluid observed once every other day. All the necessary care was individually given to the patients during the therapy. All patients properly received combined therapy including a low-fat and low-sodium diet, and diuretic and peritoneal drainage. The volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from 2,000 to 50 ml with a clear appearance and negative qualitative analysis of chyle. For those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. In conclusion, Octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce triglyceride levels in ascites. It appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis.

Antithrombin activity in children with chylothorax.

OBJECTIVE: To determine whether increased antithrombin loss is present in children with chylothorax after cardiac surgery. METHODS: Plasma and pleural effusion samples of children with chylous and non-chylous pleural effusion were assayed for antithrombin activity. RESULTS: Ten children with chylothorax and five children with non-chylous pleural effusion were investigated. There was statistically significant increase in mean antithrombin activity in chylous samples (32.2+/-11.4%) compared to non-chylous samples (14.4+/-13.9%), and significant decrease in plasma of children with chylothorax (44.6+/-15.4%) compared to children with non-chylous pleural effusion (69.9+/-22.4%). Seven of 10 children with chylous and none of the children without chylous developed thrombosis (p<0.007). CONCLUSIONS: Increased loss of antithrombin is present in children with chylothorax, potentially predisposing these children to an increased risk of thrombosis. Repeated antithrombin substitution should be considered in critically ill children with chylothorax.

Use of orlistat (xenical) to treat chylous ascites.

Chylous ascites is uncommon and occurs in about 1 in 20,000 hospital admissions. Causes include disruption of the lymphatic system due to malignancy, cirrhosis, surgery, or radiation therapy. The mainstay of therapy has been low-fat diet supplemented with medium-chain triglyceride oil. However, dietary compliance can be difficult to achieve for adequate response. We report a 47-year-old man with hepatitis C and alcohol-related cirrhosis with new-onset chylous ascites and chylothorax. His ascites triglyceride was 585 mg/dL, and the pleural fluid triglyceride was 691 mg/dL. Ascitic and pleural fluid cytology and acid-fast bacilli stain were negative. The patient was treated with low-fat diet and medium-chain triglyceride oil. However, his ascites remained chylous after 1 week of treatment because of poor compliance with the dietary restrictions. Orlistat was then added to his treatment regimen. A half week later, the chylous component of his ascites resolved. Remaining high-volume clear ascites was treated with placement of a transjugular intrahepatic portosystemic shunt. To our knowledge, orlistat has never been used in the treatment of chylous ascites. This case suggests the potential value of adding orlistat to low-fat diet and medium-chain triglyceride oil in the treatment of chylous ascites, especially in patients who are unable to comply with the dietary restrictions.

Spontaneous healing of chylous ascites after abdominal aortic aneurysm repair.

Postoperative chylous ascites is a rare complication of aortic surgery. This report presents a patient with chylous ascites after abdominal aneurysmectomy. After a retrospective analysis of full blood count measurements, we observed an association between the number of lymphocytes in the patient's total blood count and the development and evaluation of chylous ascites. We believe that this hypothesis might be helpful, as it suggests that the number of lymphocytes in a patient's total blood count may be used as a prognostic factor for the development of chylous ascites. Furthermore, our patient appears to be of interest from a therapeutical point of view, since repeated therapeutic paracenteses alone were sufficient in treating chylous ascites, a finding in contradiction to international literature.

Lymphangiomyomatosis associated with chylous ascites and high serum CA-125 levels: a case report.

A case of lymphangiomyomatosis with marked chylous ascites and persistently elevated CA-125 levels is presented. A 30-year-old woman revealed milky urine, milky ascites and exertional dyspnea about one year after the normal delivery of her second child. The lungs showed bilateral diffuse reticular shadows. No pleural effusion was observed. Pulmonary function tests revealed hypoxemia and obstructive changes of the respiratory tract. The levels of CA-125 in blood and ascites were continuously more than 200 U/ml. The inguinal lymph node biopsy and open lung biopsy confirmed the diagnosis of lymphangiomyomatosis. The patient was first treated with progesterone without effect. Oophorectomy was then performed, resulting in the improvement of respiratory distress, although ascites continued. With addition of Le Veen's peritoneojugular shunt the patient improved with reduction of ascites.