Chylous Ascites and Pleural Effusion Treated with Intravenous Octreotide

Abstract

Chylous ascites is uncommon. A few case reports have been described in cirrhotic patients. It usually presents as refractory ascites and treatment options are limited. Use of octreotide in management of chylous ascites is limited to case reports and series.(2) We describe the case of a 59 year-old-female who presented with chylous ascites and was managed with octreotide with significant reduction in ascitic volume. A 59-year-old female with past medical history of alcoholic cirrhosis was admitted to the intensive care unit (ICU) with hypoxic respiratory failure. On examination, she had diminished breath sounds, abdominal ascites with shifting dullness. Her hypoxia was attributed to compressive atelectasis from hepatic hydrothorax and from hepato-pulmonary syndrome. She underwent diagnostic and therapeutic thoracentesis and paracentesis. Analysis of both ascitic and pleural fluid revealed presence of triglyceride containing fluid. Microbiological work up was negative. No malignant cells were identified. She was started on optimal diuretic therapy for portal hypertension. She received repeated paracentesis with removal of about 2-3 liters of fluid every 3-4 days. Because of rapid re-accumulation of ascitic fluid, a peritoneal drainage catheter was placed. She was started on treatment with octreotide at 100 micrograms three times a day for five days. Remarkable improvement in ascitic fluid production was seen. Over the five days of treatment, her ascitic fluid drainage reduced from 600 mL per day to 25 mL per day as shown in the figure (Figure 1). With this, her hypoxia improved significantly, patient was discharged. She underwent TIPSS (trans jugular intrahepatic portosystemic shunt) as outpatient and had improvement in her overall functional status. She is being evaluated for liver transplantation.2445 Figure 1. showing ascitic fluid volume by daySpontaneous chylothorax after liver cirrhosis is uncommon. Chylous ascites can occur as an initial presentation or during later stages of cirrhosis with complications from hepatocellular carcinoma, TIPSS or during procedures related to complications from cirrhosis [sclerotherapy related thoracic duct injury]. It has been attributed to portal hypertension leading to increased pressure in the small intestinal lacteals that can cause minute lymphatic rupture. Octreotide helps in improving portal hypertension and decreasing triglyceride level in ascitic fluid.