What is Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)?
Chylous ascites, or CA, is a condition where a milky, fatty fluid fills up the abdomen. First observed in 1912, this rare condition is a buildup of a type of lymph fluids that originate from the chest or intestines. Many causes have been identified, including trauma, blockage leading to a rupture of the lymphatic vessels, or increased pressure in the abdomen’s lymphatic system.
This fluid is loaded with nutrients and antibodies, which are key for our body’s normal functions. However, once these elements are trapped in the abdomen, the body can’t utilize them. This can cause dehydration, imbalances in body salts, malnutrition, and a weakened immune system.
It’s a serious condition, with a death rate that can be as high as 40% to 70%, depending on what caused it to develop. This is why it’s crucial to diagnose and treat it as quickly as possible.
What Causes Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)?
Chylous ascites, a condition characterized by a buildup of a fatty fluid in your abdomen, can be caused by many different things. These causes can generally be categories as trauma-related, due to inflammation, a result of surgery, associated with cancer, stemming from infection, or present from birth (congenital) or acquired over time. The disease can also be influenced by whether the portal system, an important part of our body’s blood circulation, is affected or not.
In western countries, the main causes of this condition are usually abdominal cancer and liver disease known as cirrhosis. But in developing and eastern countries, infections such as tuberculosis and filariasis are often the main culprits.
A study of 190 patients with chylous ascites found 41 different causes. Most commonly, the cause was abnormalities in the lymphatic system, a part of the immune system (32% of cases), particularly in children. The second most common cause was cancer (7% of cases). Liver disease and infections caused by mycobacteria, a type of bacterium, were identified as the cause in 11% and 10% of cases, respectively.
Risk Factors and Frequency for Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
In 1992, a big university hospital estimated that about 1 in every 20,000 patients admitted over the course of 20 years will have a condition called chylous ascites (CA). Due to advanced care and better treatment for cancer patients, which has resulted in increased survival rates, the occurrence of CA has probably risen. CA can be a serious condition, with high death rates from 40% to 70% depending on its cause.
Signs and Symptoms of Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
When a person with ascites goes to the doctor, the evaluation usually starts with an in-depth look at the patient’s symptoms and medical history. This history review might include knowledge of any past illnesses like cancer, liver or kidney disease, any recent injuries, family health history, previous surgeries, and travel or social habits.
Chylous ascites, a specific type of ascites, mostly leads to painless and gradual swelling of the abdomen over weeks or months. This is the most common symptom and affects up to 81% of patients. Some patients may have less common symptoms like stomach pain, inflammation of the abdominal lining (peritonitis), diarrhea, difficulty swallowing (dysphagia), swelling in the arms and legs (peripheral edema), weight gain and shortness of breath due to increased abdominal pressure. Other vague symptoms can include loss of appetite, tiredness, nausea, swollen lymph nodes, a feeling of fullness, fever, and night sweats.
During a physical exam, the doctor might note a swollen and possibly firm abdomen upon touch. Some classic signs of ascites, like shifting dullness and fluid wave (a transmission thrill), may also be noticed. The presence of surgical scars could hint at an injury-related cause. Enlarged lymph nodes may also be apparent. If the patient has other conditions like cancer, kidney, or liver disease, these can act as additional clues. For instance, patients with advanced stage liver disease (cirrhosis) may have noticeable physical signs such as loss of body mass, yellowing of the skin (jaundice), thinning of the muscles in the temporal areas of the head, red palms, small spider-like blood vessels visible on the chest and abdomen, male breast enlargement, decreased breath sounds or dullness upon chest tapping due to fluid buildup in the chest cavity, a firm abdomen due to ascites, a condition called caput medusae (where the veins around the belly button become distended), and confusion or disorientation in severe cases (hepatic encephalopathy).
Some specific physical signs can point to specific conditions like yellow-nail syndrome or Klippel-Trenaunay syndrome.
Testing for Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
To diagnose and assess the condition known as chylous ascites (CA), doctors need to conduct blood and fluid tests. The standard blood tests include a complete blood count, basic metabolic panel, lipid profile, liver function tests, total protein, albumin, lactate dehydrogenase (LDH), amylase, and lipase.
Additional tests might be suggested depending on the patient’s symptoms and their specific case. These could include the following:
An abdominal paracentesis can be an essential part of diagnosing CA. This is when a doctor removes a small amount of fluid from the belly area for testing. If the fluid appears milky, doctors may suspect CA. If the concentration of triglyceride (a type of fat) in the fluid is over 200 mg/dL, it supports the diagnosis of CA. The fluid is also checked for the presence of fat globules and white blood cells known as lymphocytes. If there is suspicion of tuberculosis, further tests such as an acid-fast bacilli smear, culture, and polymerase chain reaction (PCR) may be done. Sometimes a tissue sample from the peritoneum (the lining of the abdomen) may be needed.
Lipoprotein electrophoresis (a type of blood test) is considered the best method for diagnosing CA, because it identifies chylomicrons (a type of fat). High levels of triglyceride in the fluid are the key indicator of CA. A recent study suggested that a certain range of triglyceride levels could conclusively establish CA.
Cytology (study of cells) and peritoneal biopsy (i.e., taking a small sample of tissue from the peritoneum for testing) are also crucial diagnostic tools for CA.
A computed tomography (CT) scan of the abdomen may be useful to detect abdominal masses and lymph nodes, which can sometimes occur in cases of CA. The pathognomonic feature of CA on a CT scan is a fat-fluid level, which can be observed when the patient lies on their back for a while before the scan. The fat-fluid level could also be seen with ultrasonography.
Lymphangiography (a special type of X-ray of the lymphatic system) may be used in cases where lymphatic obstruction is suspected. This method, and another known as lymphoscintigraphy, are effective for patient selection for surgery, monitoring the treatment outcomes, detecting abnormalities in the retroperitoneal nodes (lymph nodes in the abdomen), and for detecting any leaks, fistulas or spreading of the thoracic duct.
In addition, a substance called CA-125 may be notably elevated in patients with cirrhosis (scarring of the liver) and chylous ascites.
Treatment Options for Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
Treating chylous ascites (CA), a condition involving an abnormal buildup of fluid in the abdomen, can be difficult due to limited treatment options. Doctors usually aim to manage the health issue causing CA and apply strategies to improve the patient’s comfort, decrease the chances of the issue recurring, and enhance treatment outcomes.
One strategy is a healthy diet. Doctors could suggest a diet low in fat, particularly one filled with medium-chain triglycerides, and high in protein. These specific fats are beneficial because they are easily absorbed by the body’s cells and delivered directly to the liver. If diet modification is not enough, patients might need to rest their digestive tract and receive total parenteral nutrition (TPN), meaning they get required nutrients through an IV. Healthcare professionals who specialize in nutrition can help with TPN management and choosing the right fat components for the diet.
Medication might also help decrease CA. For example, orlistat can lower the absorption of fatty acids by halting lipase, a fat-digesting enzyme. The body’s naturally occurring hormone, somatostatin, and its synthetic version, octreotide, may also treat CA. These drugs can lessen pressure in the portal vein (a large vein leading to the liver), cut down on the movement and fat absorption in the gut, and reduce the flow of lymphatic fluid. Octreotide has been used successfully in treating CA caused by certain conditions like pancreatitis and liver transplant.
Etilefrine, a drug designed to treat low blood pressure, can be used to decrease the flow of chyle, a type of lymph fluid. This drug does so by tightening the muscles in the thoracic duct, a major channel in the lymph system.
Other therapeutic strategies may help as well. One is lymphangiography with embolization, a procedure where a sticky substance is injected into a lymph node to stop fluid flow. Another way to manage CA is with abdominal paracentesis, a temporary solution where fluid is removed from the abdomen. For patients with liver disease, they may replace some proteins removed with the fluid. Paracentesis is most effective when used alongside other conservative treatments.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a procedure used for patients with liver cirrhosis who fail to improve with conservative treatments. In this procedure, a channel is made in the liver to relieve pressure in the abdominal veins.
If medical therapy fails or isn’t suitable, a peritoneovenous shunt can be considered. This shunt reroutes the lymph fluid back into the bloodstream. However, it may cause complications like electrolyte abnormalities, septic shock, and obstruction of the small intestine.
Surgery might be an option if other treatments don’t work, especially if CA is due to birth defects, prior surgery, or cancer. The surgery could involve placing a shunt, closing a fistula, or removing a tumor, usually requiring a large abdominal incision.
What else can Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides) be?
Chylous ascites, a rare condition, could be caused by various other health issues. Doctors may need to rule out the following possible causes:
- Cancers such as lymphoma, leukemia, or sarcomas (including Kaposi’s sarcoma)
- Solid tumors
- Neuroendocrine tumors
- Infections like mycobacterial infections and filariasis
- Autoimmune diseases, for example, SLE or sarcoidosis
- Pancreatitis, an inflammation of the pancreas
- Superior vena cava syndrome, a blockage of the superior vena cava, a major vein in the body
- Cirrhosis, a liver disease
- Birth defects in the lymphatic system, such as Waldmann disease, yellow-nail syndrome, or Klippel-Trenaunay syndrome
It’s vital that the doctor considers all these conditions and carry out necessary tests to arrive at the right diagnosis.
What to expect with Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
The outlook for patients with a condition called chylous ascites (CA) depends on what’s causing it. CA can be linked to a high rate of death, as much as 40% to 70%. It can also make a person very sick. The outlook tends to be worse for CA cases that aren’t related to surgery.
Even though cancers are a common cause of CA, it’s been noticed that treating them, especially lymphomas (a type of cancer), can improve the patient’s chance of survival. This is largely due to the recent development of better chemotherapy treatments and the use of certain types of proteins made in a lab to attack cancer cells.
Before these new treatments were introduced, CA that occurred along with lymphomas, usually resulted in a poor outlook, with 90% of patients passing away within three months.
Possible Complications When Diagnosed with Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
Chylous ascites is a condition where nutrients and disease-fighting proteins accumulate in the abdominal cavity. This leads to fluid loss, poor nutrition, electrolyte imbalance, and weakened immunity. As a result, it’s crucial to diagnose and treat this condition properly.
Over time, excessive pressure in the lymphatic system can lead to the buildup of a protein called collagen in the layer beneath our skin and other tissues. This buildup reduces the gut’s ability to absorb nutrients, leading to a condition known as protein-losing enteropathy.
Preventing Chylous Ascites (Milky Fluid in the Abdomen High in Fat or Triglycerides)
Teaching patients about their condition is key to managing a certain type of fluid buildup in the abdomen known as chylous ascites (CA), as well as its underlying causes. It’s particularly important for patients to understand the crucial role of changing their diet as a primary step in dealing with CA. A diet high in protein but low in fat, specifically including medium-chain triglycerides (MCTs), is generally suggested for symptom relief in CA patients.
MCTs can be found in several food items, such as palm and coconut oil, as well as full-cream milk, cheese, and butter, which contain substances known as capric and lauric acid. However, patients need to steer clear of other oils and fats, including nuts, red meat, fish, olive oil, and avocados because these contain long-chain triglycerides (LCT).
It’s also worth noting that MCTs may not be to everyone’s taste and may lead to bloating, which can cause patients to stop adhering to the diet if they experience nausea and vomiting. So, it’s necessary to prepare patients for these potential side effects. Finally, for those patients whose CA is due to liver cirrhosis, it’s important for them to follow a low-sodium diet and take diuretics or water pills, along with discussing this with their doctor.
