Chylous Ascites

Abstract

When a condition appears rarely and sporadically, few clinicians have the opportunity to collect adequate information and to develop interest and expertise. Such is the case with chylous ascites and, as a result, many aspects of this phenomenon remain poorly understood. The pathophysiology has not been clearly defined, the underlying disease often proves elusive with present diagnostic procedures, and effective therapy is frequently not possible. The incidence has not been satisfactorily established; at Charity Hospital of Louisiana, New Orleans, there was approximately one patient per 100,000 admissions from 1936 to 1956.1 The actual occurrence of chylous ascites is probably higher, as the condition is usually unsuspected; the patient may die or the process resolve without the presence of the condition being revealed by paracentesis. In addition, the incidence is probably not constant, and is likely to vary as etiological factors vary with geographical area (eg, filariasis) or with the prevalence of certain diseases (eg, tuberculosis).Chylous ascites or chyloperitoneum is a manifestation or symp¬ tom and not a disease entity. It is the collection within the peritoneal cavity, as a result of interference, interruption, or obstruction of lymph flow through chyle-transporting ves¬ sels, of fluid which appears milky due to the presence of unusual amounts of fat. The fat occurs pri¬ marily as triglycérides, usually with associated small amounts of choles¬ terol and phospholipids.1"3 The cri¬ teria often used to define a chylous effusion are a lipid content greater than that of plasma, a protein con¬ tent more than half that of plasma, and the presence of microscopic fat.These criteria cannot be rigidly maintained since exceptions can be found to each of them. Microscopic fat may be absent 4 ; its presence is a function of the physical state of sus¬ pended lipids. Fat and protein con¬ centrations are dependent upon dietary as well as other factors, and considerable variation might be anticipated. Effusions of unquestion¬ able chylous origin have, upon oc¬ casion, been shown to contain <2 gm/100 ml of protein and <350 mg/ 100 ml of lipid.2"" However, the neu¬ tral fat : total lipid ratio is almost universally higher than that of plas¬ ma.2-5 The only lymphatic fluids ap¬ proaching these high contents of fat and protein are those drained from the intestine and possibly the liver; the similar relative composition of chylomicrons suggests the origin of the effusion.In view of this it is useful to ex¬ amine some pertinent aspects of lipid digestion and absorption. About one third of dietary triglycérides are termed medium and short chain (MCT) ; these are composed of fatty acids with fewer than 12 carbon atoms (largely caprylic, capric, lauric, and caproic acids). These tri¬ glycérides probably enter the intes¬ tinal wall intact, are broken down within the cell, and the resultant free fatty acids and glycerol are transported directly to the liver by the portal vein. Pancreatic enzymes are not required for digestion and abs...

Ascites in Chronic Leukemia

“…In the liver this can cause hepatic vein occlusion [6], Chylous ascites [1,5] apparently can also be seen. However, in a recent review of chylous ascites [15] no cases of leukemia are des cribed. In addition, infiltration of the heart leading to congestive heart failure, and infiltration of the kidneys with development of nephrosis are potential etiologies for ascites (though none have been described in leu kemics).…”