Journal of Clinical and Experimental Hepatology

Conservatively Managed Chylous Ascites in Cirrhosis – A Case Series

--Manuscript Draft--

Manuscript Number:

Article Type: Case Report

Keywords: - Chylous ascites; octreotide; Low Fat Diet; Paracentesis; cirrhosis

Corresponding Author: Faisal Rasheed, MD

Batra Hospital and Medical Research Centre
New Delhi, Delhi INDIA

First Author: Faisal Rasheed, MD

Order of Authors: Faisal Rasheed, MD

Kapil Sharma, MD, DM

Vasudha Goel, MD, DM

Mumina Ramzan, MD

Abstract: Introduction

Chylous ascites is a rare condition in decompensated cirrhotic patients characterized

by accumulation of milky fluid, rich in triglycerides. These patients generally present
with multiple comorbidities, making them unsuitable for treatment options like TIPS
(Transjugular Intrahepatic Portosystemic Shunts). Chylous ascites is a refilling ascites
requiring frequent paracentesis, leading to increased morbidity, hospital admission and
cost. These patients do not respond to high protein, salt restricted diet and diuretics.
Limited data is available on use of subcutaneous (s/c) octreotide (OCT) and low fat diet
(LFD) in these patients.

Methods

We prospectively observed 3 patients who presented with tense chylous ascites who
had undergone multiple large volume paracentesis. They were on highest tolerable
dose of diuretics, compliant to salt restriction and had not undergone TIPS either due
to contraindications or denial of consent. These patients were evaluated for
malignancy, infection (tubercular), pancreatitis, and cardiac disease. They were
advised low fat diet and Injection octreotide 100mcg subcutaneously thrice daily, for
three months. They were followed up on low fat low salt and high protein diet, diuretics
after stopping OCT and observed for total period of 7 months.

Results

Patients advised with LFD and OCT in combination with standard medical treatment
showed decreased need for paracentesis and had well controlled ascites. These
patients showed resolution of chylous ascites in the first month of starting treatment
and effect persisted even after stopping octreotide.

Conclusion

Chylous ascites treated with LFD and OCT showed decreased need for LVP and
persistence of effects even after stopping OCT. It should be considered as a first line
treatment for refilling chylous ascites in patients not fit for TIPS or Liver
Transplantation.

Suggested Reviewers: Anoop Saraya, MD, DM

Professor, AIIMS New Delhi
[email protected]
Expert in field

Sanchit Singh, MD, DrNB

Consultant, Max Super Speciality Hospital Vaishali

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Cover Letter

Title – Conservatively Managed Chylous Ascites in Cirrhosis – A Case Series

Faisal Rasheed1, Kapil Sharma1, Vasudha Goel1, Mumina Ramzan1

1 – Batra Hospital and Medical Research Centre New Delhi

Authors

Faisal Rasheed1, Kapil Sharma1, Vasudha Goel1, Mumina Ramzan1

Corresponding Author

Faisal Rasheed
MD (Internal Medicine)
Senior Registrar Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
Email Id- [email protected]
No financial Disclosure

Co-authors

Kapil Sharma
MD (Internal Medicine)
DM (Gastroenterology)
Senior Consultant and HOD Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
E mail Id- [email protected]
Telephone no- +917023176653
No financial Disclosure

Vasudha Goel
MD (Internal Medicine)
DM (Gastroenterology)
Consultant Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
E mail Id- [email protected]
No financial Disclosure

Mumina Ramzan
MD (Internal Medicine)
Senior Registrar Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
Email Id- [email protected]
No financial Disclosure
Manuscript Click here to view linked References

Conservatively Managed Chylous Ascites in Cirrhosis – A Case Series

1
2 Faisal Rasheed1, Kapil Sharma1, Vasudha Goel1, Mumina Ramzan1
3 1 – Batra Hospital and Medical Research Centre New Delhi
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6
7 ABSTRACT
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Introduction– Chylous ascites is a rare condition in decompensated cirrhotic patients
10 characterized by accumulation of milky fluid, rich in triglycerides. These patients generally
11 present with multiple comorbidities, making them unsuitable for treatment options like TIPS
12 (Transjugular Intrahepatic Portosystemic Shunts). Chylous ascites is a refilling ascites
13 requiring frequent paracentesis, leading to increased morbidity, hospital admission and cost.
14
15 These patients do not respond to high protein, salt restricted diet and diuretics. Limited data is
16 available on use of subcutaneous (s/c) octreotide and low fat diet (LFD) in these patients.
17 Methods – We prospectively observed 3 patients who presented with tense chylous ascites
18 who had undergone multiple large volume paracentesis. They were on highest tolerable dose
19
of diuretics, compliant to salt restriction and had not undergone TIPS either due to
20
21 contraindications or denial of consent. These patients were evaluated for malignancy,
22 infection (tubercular), pancreatitis, and cardiac disease. They were advised low fat diet and
23 Injection octreotide 100mcg subcutaneously thrice daily, for three months. They were
24 followed up on low fat low salt and high protein diet, diuretics after stopping octreotide and
25
26 observed for total period of 7 months.
27 Results – Patients advised with LFD and octreotide in combination with standard medical
28 treatment showed decreased need for paracentesis and had well controlled ascites. These
29 patients showed resolution of chylous ascites in the first month of starting treatment and
30 effect persisted even after stopping octreotide.
31
32 Conclusion – Chylous ascites treated with LFD and octreotide showed decreased need for
33 LVP and persistence of effects even after stopping octreotide. It should be considered as a
34 first line treatment for refilling chylous ascites in patients not fit for TIPS or Liver
35 Transplantation.
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38 Keywords – Chylous ascites, octreotide, Low Fat Diet, Paracentesis, cirrhosis
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40 Abbreviations - AKI - Acute kidney injury, LFD – Low Fat Diet, LVP – Large volume
41 paracentesis,TIPS - Transjugular Intrahepatic Portosystemic Shunts, SAAG - Serum Ascites
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43 Albumin Gradient, SBP - Spontaneous Bacterial Peritonitis.
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45 Introduction – Chylous ascites is accumulation of milky, triglyceride rich fluid in the
46 peritoneal cavity. Among patients with atraumatic chylous ascites, malignancy is the most
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common cause, followed by cirrhosis, and tuberculosis [1]. In a developing country like
49 India, tuberculosis accounts for a significantly high proportion of patients. The prevalence of
50 chylous ascites in cirrhotics is only 0.5% - 1% [2]. In cirrhosis lymphatic flow is increased,
51 along with the number and density of lymph vessels, leading to lymphatic oversaturation and
52 flow dysfunction [3-5]. A triglyceride concentration of more than 200 mg/dL in ascitic fluid
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54 is needed for the diagnosis1. Chylous ascites in cirrhotics is refilling ascites, that needs
55 multiple Large Volume Paracentesis (LVP) despite being on salt restricted diet and maximum
56 tolerable dose of diuretics. Need for multiple LVP and high dose diuretics causes circulatory
57 dysfunction and acute kidney injury (AKI), adding to the morbidity, need for hospitalization
58
and mortality. Transjugular Intrahepatic Portosystemic Shunt (TIPS) has been found to be an
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60 effective option for refilling ascites needing multiple frequent LVP. Though not all patients
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 are candidates for TIPS, non-invasive options like Low Fat Diet (LFD) and Octreotide have
1 not been largely studied and their long-term outcomes are not reported. Only few case reports
2 have been published regarding use of octreotide in chylous ascites in cirrhotics [6,7]
3
4
5 Case Series
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7 Case 1 – A 45-year-old male, diagnosed with decompensated alcoholic cirrhosis for two
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9
years, with history of prior hepatic encephalopathy, presented with worsening of ascites
10 which was earlier stable on diuretics and salt restricted diet. For this, he underwent 4 large
11 volume paracentesis with drainage of 20 litres of ascites one month before presentation.
12 Patient was admitted, and evaluated for worsening of ascites. Investigations showed
13 Hemoglobin 9.3 g/dL, serum creatinine 2.7 mg/dL, and serum albumin of 2.3 g/dL. In view
14
15 of AKI patient was started on serum albumin 1g/kg on day 1 and day 3. Diagnostic ascitic tap
16 was performed which showed high SAAG (Serum Ascites Albumin Gradient) ascites, and no
17 evidence of tuberculosis / SBP (Spontaneous Bacterial Peritonitis) and high triglyceride
18 levels (369 mg/dL) (table 1). His serum creatinine improved by day 4. In view of chylous
19
ascites patient was started on Low Fat diet, and octreotide (100 mcg, subcutaneously eight
20
21 hourly). Patient needed only one LVP after starting treatment and cleared triglyceride in the
22 first month of treatment (table 2). Patient was continued on treatment for 3 months, after
23 which octreotide was stopped and patient was continued on LFD and observed for next 4
24 months. During this period, he showed controlled ascites on diuretic and LFD therapy
25
26 needing only one LVP, with no relapse of chylous ascites.
27
28 Case 2 – Our second patient was a 65 year-old long standing diabetic diagnosed with chronic
29 liver disease on evaluation for ascites 2 months back. Patient was started on diuretics and
30 underwent multiple LVP, and presented to us with worsening ascites. His blood
31
32 investigations showed moderate anemia (Hb- 7.4g/dL), serum creatinine of 1.1mg/dL, serum
33 albumin 2.8g/dL. Ascitic fluid analysis showed high SAAG ascites, triglyceride value of
34 843mg/dL and no evidence of tuberculosis/SBP. Triple phase CT abdomen showed partial
35 thrombus in main portal vein (table 1). Patient was started on octreotide (100 mcg s/c eight
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hourly) and LFD. Patient showed some improvement in ascites formation by 1 month, which
38 significantly improved by 3 months. Octreotide was stopped after 3 months of treatment and
39 patient was followed for a total of 7 months. During this period patient underwent single
40 paracentesis of 2.5 liters and was controlled on diuretic and low-fat diet (table 2).
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 1
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5 Table 1 – Patient baseline characteristics
6 Case 1 Case 2 Case 3
7
Hemoglobin (g/dL) 9.3 7.4 10.6
8
9 Total leucocyte count (/µL) 5880 7260 5690
10
11 Platelet (103/µl) 140 95 122
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13 Urea / creatinine (mg/dL) 68/2.7 18/1.1 67/1.9
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15 Total bilirubin (mg/dL) 1.76 1.09 2.1
16
17 AST/ALT/ALP (IU/L) 51/35/178 61/53/71 34/28/67
18 Serum albumin (g/dL) 2.3 2.8 2.6
19 AFP (ng/mL) 2.26 2.2 3.2
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21 PT (sec)/INR 14.2/1.24 16.1/1.45 15.1/1.39
22 Serum ammonia (µg/dL) 57 291 109
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25 Ascitic Fluid
26 TLC (/µL)/ DLC 150 / N20%L50 180 / N37%L63% 280 / N25%L75%
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29 Protein / Albumin (mg/dL) 2.4 / 0.9 2.13 / 1 2.4/0.8
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31 ADA (U/L) 4.9 2.6 3.1
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34 Triglyceride (mg/dL) 369 843 626
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36 LDH (U/L) 127 193 110
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39 Gene X-pert MTB Negative Negative Negative
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Cytology for malignant cells Negative Negative Negative
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46 Chest x-ray Normal, no PE Normal, no PE Mild Right side
47 PE
48 Echo Normal LV/RV Normal LV/RV Normal LV/RV
49 function function function
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51 CT abdomen (triple phase) Features of CLD, Features of CLD, Features of CLD,
52 no liver SOL no liver SOL. no liver SOL
53 Partial thrombus
54 in MPV
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UGI endoscopy Small EV Post EVL Small EV
57 CTP Score 9 8 10
58 MELD 20 12 19
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 PE – Pleural effusion, LV- left ventricle, RV – right ventricle, CLD- Chronic liver disease,
1 SOL- Space occupying lesion, MPV- main portal vein, EVL- Esophageal Variceal Ligation.
2
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4
5 Case 3 – 49-year-old male patient, diagnosed as decompensated alcoholic liver disease,
6 alcohol abstinent, was controlled on diet and diuretic therapy for three years. He developed
7 new onset refilling ascites, and underwent three LVP with drainage of around 15 liters of
8
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fluid. Ascites was high SAAG low protein, with no evidence of tuberculosis/ SBP/
10 malignancy, and triglyceride level of 526 mg/dL (table 1). Patient was advised TIPS, for
11 which consent was denied. He was started on Octreotide (100 mcg s/c eight hourly) and LFD,
12 following which he underwent one LVP during stay in our hospital. He showed improvement
13 in ascites control, and was discharged after 15 days of hospital stay on diuretic, LFD and
14
15 octreotide. He was on same treatment for 3 months after which octreotide was stopped, and
16 LFD – salt restriction and diuretic were continued. He did not need any paracentesis and
17 ascites was controlled during follow up of next 4 months (table 2).
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Table 2 – Clinical events, treatment and follow up
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22 Patient 1 Patient 2 Patient 3
23 Months Paracentesis Octreotide Paracentesis Octreotide Paracentesis Octreotide
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(Liters) & low fat (Liters) & low fat (Liters) & low fat
26 diet diet diet
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28
29 Month 0 4 (20 L) No 4 (16L) No 3 (15L) No
30 Month 1 1 (6L) Yes 1 (4L) Yes 1 (11L) Yes
31 Month 2 0 Yes 0 Yes 0 Yes
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33 Month 3 0 Yes 0 Yes 0 Yes
34 Month 4 0 OCT - / 0 OCT - / 1 OCT - /
35 LFD + LFD + LFD +
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37 Month 5 0 OCT - / 1 (2.5L) OCT - / 0 OCT - /
38 LFD + LFD + LFD +
39 Month 6 1 (6L) OCT - / 0 OCT - / 0 OCT - /
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TG- 86 LFD + LFD + LFD +
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42 Month 7 0 OCT - / 0 OCT - / 0 OCT - /
43 LFD + LFD + LFD +
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45 TG- Triglyceride, OCT – Octreotide, LFD- Low Fat Diet.
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47 Discussion – Liver disease patients with chylous ascites need recurrent large volume
48 paracentesis, ultimately requiring TIPS. Patients included in this case series have not
49
undergone TIPS or liver transplantation either due to financial constraints or donor
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51 unavailability. These patients were offered octreotide with LFD, diuretics and variceal
52 ligation. Beta blockers were withheld in all cases. After three months of treatment, they
53 showed significant improvement in control of ascites, which was maintained during the
54 follow up period of four months. This is indirectly proof of concept that octreotide and LFD
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not only decreases lymphatic production resulting in ascites control, but also corrects
57 lymphatic dysfunction, resulting in a long-term effect. Further larger studies are, however,
58 needed to confirm these findings.
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 Conclusion – Combination therapy with low fat diet and octreotide yielded good control of
1 chylous ascites, resulting in decreased need for large volume paracentesis. One of the
2 hypotheses elucidating the pathogenesis of chylous ascites is increased lymphatic flow in
3
4 portal hypertension patients, leading to lymphatic rupture. In our case series, we continued to
5 give octreotide with LFD despite clinical resolution of ascites for two more months,
6 following which we observed prolonged remission in the follow up period. A plausible
7 explanation for this can be decreased lymphatic production and flow, which would have
8
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promoted lymphatic healing, in turn leading to persistence of the beneficial effect even after
10 stoppage of treatment. Therapy with octreotide and LFD can prove to be useful, especially in
11 resource limited settings. Larger studies, to reinforce this preliminary evidence, can help to
12 bring about a change in clinical practice.
13
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15 Credit Authorship statement-
16 Faisal Rasheed : Conceptualization, Methodology, Data curation, Writing- Original draft
17 preparation. Mumina Ramzan : Visualization, Investigation. Vasudha Goel: Writing-
18 Reviewing and Editing. Kapil Sharma – Supervision and Project administration.
19
20
21 Conflict of interest –
22 All authors have none to declare.
23
24 Funding –
25
26 None.
27
28 References –
29
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1. Al-Busafi SA, Ghali P, Deschênes M, Wong P. Chylous Ascites: Evaluation and
32 Management. ISRN Hepatol. 2014;2014:1-10. doi:10.1155/2014/240473
33 2. Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic
34 approach and current management of chylous ascites. Aliment Pharmacol Ther.
35
36 2017;46(9):816-824. doi:10.1111/apt.14284
37 3. Kumar R, Anand U, Priyadarshi RN. Lymphatic dysfunction in advanced cirrhosis:
38 Contextual perspective and clinical implications. World J Hepatol. 2021;13(3):300-
39
40
314. doi:10.4254/wjh.v13.i3.300
41 4. Vollmar B, Wolf B, Siegmund S, Katsen AD, Menger MD. Lymph Vessel Expansion and
42 Function in the Development of Hepatic Fibrosis and Cirrhosis. Vol 151.; 1997.
43 5. Tanaka M, Iwakiri Y. The Hepatic Lymphatic Vascular System: Structure, Function,
44
45 Markers, and Lymphangiogenesis. CMGH. 2016;2(6):733-749.
46 doi:10.1016/j.jcmgh.2016.09.002
47 6. Zhou DX, Zhou HB, Wang Q, Zou SS, Wang H, Hu HP. The effectiveness of the
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49 treatment of octreotide on chylous ascites after liver cirrhosis. Dig Dis Sci.
50 2009;54(8):1783-1788. doi:10.1007/s10620-008-0566-6
51 7. Berzigotti A, Magalotti D, Cocci C, Angeloni L, Pironi L, Zoli M. Octreotide in the
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outpatient therapy of cirrhotic chylous ascites: A case report. Digestive and Liver
53
54 Disease. 2006;38(2):138-142. doi:10.1016/j.dld.2005.05.013
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Credit Authorship Contribution Statement

Faisal Rasheed: Conceptualization, Methodology, Data curation,

Writing- Original draft preparation. Mumina Ramzan : Visualization,
Investigation. Vasudha Goel: Writing- Reviewing and Editing. Kapil
Sharma – Supervision and Project administration