High-volume Ascites Research Articles

ED diagnosis of peritoneal carcinomatosis

PurposeThe goal of our study was to better characterize new CT diagnoses of peritoneal carcinomatosis (PC) in the ED, and to evaluate how to best identify the primary lesion. Prompt identification of the source of the carcinomatosis may allow for the patient to receive early initial care from the correct clinical service.MethodsAll new CT cases of PC-like appearance identified on CT in the ED from January 2017 through July 2020. Each report and corresponding medical record were manually reviewed. Patient demographics, presence/absence of intravenous contrast, source organ predicted by the radiologist in the CT scan report, pathologic diagnosis, and amount of ascites were tabulated. Chi-tests were used to test the statistical significance of differences between groups.ResultsOf the 131 CT cases of new PC-like appearance which received workup, 108 cases had pathologically proven PC and 23 cases had no underlying malignancy yielding a positive predictive value for actual PC of 82%. The most common cause of new PC in women was gynecological (66%), and in men was of GI tract origin (57%). Concordance between radiologist prediction and final pathology was higher with intravenous contrast (58%) compared to without contrast (40%); although this difference was not statistically significant (p = 0.19). A moderate or large amount of ascites was found in more than half of GYN primaries and in adenocarcinoma of unknown primary and there was a statistically significant difference in amount of ascites between cancer primaries (p = 0.01).ConclusionA PC-like appearance on CT in the ED will likely be in patients with known malignancy, but of the new cases, there is a high PPV for it to represent new peritoneal carcinomatosis. Gynecological and GI malignancies are the most common cause in women and men, respectively, and this may help in focusing the radiologist’s search pattern. Usage of intravenous contrast may help in identifying a primary lesion, and the presence of high-volume ascites should suggest a GYN primary or adenocarcinoma of unknown primary when there is no other obvious primary lesion.

Cytohistologic immunohistochemical correlation of epithelial tubo-ovarian neoplasms: Can cell blocks substitute for tissue?

Cytologic specimens often represent the initial diagnostic material for tubo-ovarian neoplasms resulting from therapeutic paracentesis for patients presenting with high-volume ascites. However, subtyping and immunohistochemical (IHC) characterization, which have implications in preoperative management and downstream ancillary testing, are not routinely performed in many institutions. This study aims to perform cytohistologic correlation of commonly used IHC stains to establish their reliability in peritoneal fluids/washing specimens. A retrospective search of the laboratory information systems was performed to identify peritoneal fluid/washing specimens involved by borderline or malignant epithelial tubo-ovarian neoplasms and concurrent/subsequent surgical resection specimens. Cell blocks and tissue were stained for PAX8, WT-1, p53, p16, Napsin-A, estrogen receptor, and progesterone receptor, and staining between cytological and surgical specimens was compared. A total of 56 case pairs were included, with the following final diagnoses on histological examination: 37 high-grade serous carcinomas, eight clear cell carcinomas, one endometrioid adenocarcinoma, two low-grade serous carcinomas, and eight serous borderline tumors. There was perfect cytohistologic correlation for PAX8 (Lin's concordance correlation coefficient [LINCCC]=1.00) and WT-1 (LINCCC=1.00), substantial/good correlation for p53 (LINCCC=0.96), p16 (LINCCC=0.93), napsin-A (LINCCC=0.91) and ER (LINCCC=0.77), and moderate correlation for PR (LINCCC=0.54). Immunohistochemical correlation between peritoneal fluid and surgical resection specimens for tubo-ovarian neoplasms is high. Common subtypes of tubo-ovarian carcinomas can be reliably distinguished on fluids using IHC.

Plasma Exosomes of Patients with Breast and Ovarian Tumors Contain an Inactive 20S Proteasome.

Exosomes are directly involved in governing of physiological and pathological conditions of an organism through the transfer of information from producing to receiving cells. It can be assumed that exosomes are one of the key players of tumor dissemination since they are very stable and small enough to penetrate from various tissues into biological fluids and then back, thus interacting with tissue target cells. We evaluated the enzymatic activity and the level of 20S proteasome in tissue and exosomes of healthy females (n = 39) and patients with ovarian (n = 50) and breast (n = 108) tumors to reveal the critical role of exosomal cargo in the mediation of different types of metastases. Exosomes from plasma and ascites were isolated and characterized in according to International Society for Extracellular Vesicles guidelines. The level of 20S proteasome in tissue and exosomes was determined using Western blot analysis. Chymotrypsin- and caspase-like (ChTL and CL, respectively) peptidase activities of the proteasomes were determined using fluorogenic Suc-LLVY-AMC and Cbz-LLG-AMC substrates, respectively. We observed increased levels of 20S proteasome in ovarian cancer tissue and luminal B subtype breast cancer tissue as well as in plasma exosomes from cancer patients. Moreover, the level of the 20S proteasome in plasma exosomes and ascites exosomes in patients with ovarian tumors is comparable and higher in ovarian cancer patients with low volume ascites than in patients with moderate and high-volume ascites. We also found increased ChTL and CL activities in breast cancer and ovarian cancer tissues, as well as in peritoneal metastases in ovarian cancer, while proteasomal activity in exosomes from plasma of healthy females and all patients, as well as from ascites of ovarian tumor patients were lower than detection limit of assay. Thus, regardless of the type of tumor metastasis (lymphogenous or peritoneal), the exosomes of cancer patients were characterized by an increased level of 20S proteasome, which do not exhibit enzymatic activity.

Ascites volume at the time of primary debulking and overall survival of patients with advanced epithelial ovarian cancer

ObjectivesTo investigate the impact of malignant ascites volume on the outcomes of patients with advanced epithelial ovarian carcinoma who undergo primary debulking surgery.MethodsPatients diagnosed with stage III–IV epithelial ovarian carcinoma...

Ascites volume at the time of primary debulking and overall survival of patients with advanced-stage epithelial ovarian cancer

Objectives: Investigate the impact of malignant ascites volume on the overall survival of patients with advanced stage epithelial ovarian carcinoma who undergo primary debulking surgery and achieve complete gross resection. Methods: Patients without a history of another tumor diagnosed with stage III-IV epithelial ovarian carcinoma and bulky intra-abdominal disease between 2004-2015, who underwent primary debulking surgery followed by adjuvant chemotherapy and achieved complete gross resection were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was assessed and categorized as absent, low (<980 ml) and high (≥980 ml) volume. Median overall survival was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A multivariate Cox model was constructed to control for confounders. Results: A total of 1040 patients who met the inclusion criteria were identified; 50.4% had no ascites, 34.2% had low and 15.4% had high volume malignant ascites at the time of primary debulking surgery. Median patient age was 61 years, while the majority were White (87.7%), without co-morbidities (81.1%) and had serous tumors (91.8%). Groups were comparable in terms of patient race, presence of comorbidities, tumor histology and grade. Median OS of patients without malignant ascites was 59.79 months, compared to 50.33 months for those who had low volume and 41.95 months for those who had high volume malignant ascites. After controlling for patient age, race, insurance status, presence of comorbidities and tumor histology and grade, compared to patients with no malignant ascites those with low (HR: 1.37, 95% CI: 1.09, 1.72) and high volume ascites (HR: 1.94, 95% CI: 1.47, 2.55) had worse overall survival. Patients with low volume ascites had better survival compared to those with high volume ascites (HR: 0.71 95% CI: 0.54, 0.93) after controlling for the aforementioned confounders. Conclusions: Presence and volume of ascites at the time of primary debulking surgery may be associated with worse oncologic outcomes. Investigate the impact of malignant ascites volume on the overall survival of patients with advanced stage epithelial ovarian carcinoma who undergo primary debulking surgery and achieve complete gross resection. Patients without a history of another tumor diagnosed with stage III-IV epithelial ovarian carcinoma and bulky intra-abdominal disease between 2004-2015, who underwent primary debulking surgery followed by adjuvant chemotherapy and achieved complete gross resection were drawn from the National Cancer Database. Based on available information, the presence and volume of malignant ascites was assessed and categorized as absent, low (<980 ml) and high (≥980 ml) volume. Median overall survival was determined following generation of Kaplan-Meier curves and compared with the log-rank test. A multivariate Cox model was constructed to control for confounders. A total of 1040 patients who met the inclusion criteria were identified; 50.4% had no ascites, 34.2% had low and 15.4% had high volume malignant ascites at the time of primary debulking surgery. Median patient age was 61 years, while the majority were White (87.7%), without co-morbidities (81.1%) and had serous tumors (91.8%). Groups were comparable in terms of patient race, presence of comorbidities, tumor histology and grade. Median OS of patients without malignant ascites was 59.79 months, compared to 50.33 months for those who had low volume and 41.95 months for those who had high volume malignant ascites. After controlling for patient age, race, insurance status, presence of comorbidities and tumor histology and grade, compared to patients with no malignant ascites those with low (HR: 1.37, 95% CI: 1.09, 1.72) and high volume ascites (HR: 1.94, 95% CI: 1.47, 2.55) had worse overall survival. Patients with low volume ascites had better survival compared to those with high volume ascites (HR: 0.71 95% CI: 0.54, 0.93) after controlling for the aforementioned confounders. Presence and volume of ascites at the time of primary debulking surgery may be associated with worse oncologic outcomes.

An Audit of Management of Chronic Pancreatitis with Pancreatic Ductal Disruption Resulting in Ascites and Pleural Effusion

Introduction: Pancreatic Ductal Disruption (PDD) may remain a localised collection to form pseudocyst or dissect into adjacent organs or rupture freely into the peritoneal cavity or pleural cavity resulting in massive or high-volume ascites or pleural effusions. The management of pseudocyst is well known among general and gastrosurgeons, but ascites and plural effusion remain difficult decisions. Depending on the availability of resources total parenteral nutrition, octreotide, pancreatic duct stenting are used with varying success. There are no guidelines as to which intervention is preferable in different clinical scenarios. Aim: To audit the clinical characters and management of patients with pancreatic ascites and pleural effusion. Materials and Methods: This study was done at the Department of Surgical Gastroenterology, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India. Fifty two patients with pancreatic ascites or pancreatico pleural fistula in the background of chronic pancreatitis satisfying both inclusion and exclusion criteria were identified and studied from the prospectively maintained database of patients with chronic pancreatitis in the period from September 2010 to September 2020. The patients were classified as conservatively managed, endoscopic main pancreatic duct stenting or surgery. Statistical analysis was done using windows excel. The results were expressed as percentage, mean and Standard Deviation (SD). Results: Five patients with ascites and two patients with pleural effusion responded completely to conservative measures (13.4%). In one of them ascites recurred at two months and one had left pleural effusion recurrence at one month. Fifteen patients died while on conservative management (68.2% mortality). Among eight patients undergoing endoscopic pancreatic duct stenting, ascites/pleural effusion resolved in six (75% success rate) and remained asymptomatic during mean follow-up of 12 months. Two patients who were not improving after stenting were lost to follow-up. Twenty-two patients underwent surgery namely lateral pancreatojejunostomy with resolution of symptoms. Two patients undergoing surgery died in postoperative period due to sepsis and chest infection (9.1% mortality). At a mean follow-up of 14 months they remained symptom free. Conclusion: Conservative management alone has high mortality. Early aggressive management can aim to stop leak either by pancreatic duct stenting or surgical lateral pancreatojejunostomy will help reduce mortality and morbidity.

Anesthetic management of a dog with severe subaortic stenosis and mitral valve disease complicated with atrial fibrillation undergoing ovariohysterectomy

The anesthetic management in patients with subaortic stenosis and mitral valve disease should involve intensive monitoring and the anesthesiologist’s main concern is to ensure oxygen delivery and tissue perfusion. Since anesthetic procedures in such patients are rare, there is no previous report about the anesthetic management. A 5.5-year old, 32-kg Boxer, suffering a severe heart disease due to a final stage subaortic stenosis and mitral insufficiency, was anesthetized for an ovariohysterectomy to remove an ovarian tumor that was producing high-volume ascites. Methadone (0.3 mg kg−1) was administered intramuscularly (IM) for pre-anesthetic medication, etomidate (1.3 mg kg−1) and midazolam (0.2 mg kg−1) were used for the induction of anesthesia and after endotracheal intubation, anesthesia was maintained with sevoflurane vaporized in oxygen and air. Fentanyl (5–10 μg kg−1 h−1) and paracetamol (15 mg kg−1) were administered to improve analgesia. Previous persistent atrial fibrillation was refractory to medication (digoxin, diltiazem, and pimobendan) and continued during the anesthetic procedure. Dobutamine (1.5–5 μg kg−1 minute−1) helped to maintain mean arterial blood pressure above 60 mmHg. Epidural morphine (0.1 mg kg−1) and incisional bupivacaine (2 mg kg−1) were administered at the end of surgery to provide postoperative analgesia. Anesthesia was otherwise uneventful, and recovery was considered excellent.

Double-blind randomized controlled trial of the routine perioperative use of terlipressin in adult living donor liver transplantation.

Perioperative terlipressin (Tp) during living donor liver transplantation (LDLT) has been shown to reduce intraoperative portal pressures and improve renal function. Its role and safety profile have never been evaluated in a double-blind randomized controlled trial (RCT). The aim was to evaluate the hemodynamic effects, clinical benefits, and safety of perioperative Tp infusion in adult LDLT. This was a single-center double-blind RCT. Consenting adults with chronic liver disease and low risk of posttransplant renal dysfunction undergoing their first LDLT were randomized. The study group (terlipressin group [TpG]) received an initial bolus of Tp during surgery followed by a Tp infusion for 72 hours in the postoperative period. The placebo group (PbG) received a saline infusion. The primary endpoint was portal pressure after arterial reperfusion. Multiple intraoperative and postoperative variables served as secondary endpoints. A total of 41 patients were enrolled in the trial (TpG, 21; PbG, 20). There were no significant differences in intraoperative portal pressures, blood loss, fluid requirement, vasopressor requirement, or urine output. Peak intraoperative and end of surgery lactate levels were significantly higher in the Tp group. There was no difference in postoperative liver function tests. Incidence of acute kidney injury as assessed by Risk, Injury, Failure, Loss, and End-Stage Kidney Disease criteria was lower in the Tp group (27% versus 60%; P = 0.04). The TpG had less postoperative ascites, a lower need for percutaneous interventions, and a shorter hospital stay. Incidence of bradycardia requiring pharmacological intervention and withdrawal from study was significantly higher in the TpG. In conclusion, this study has not demonstrated a reduction in postreperfusion portal pressure with Tp. However, Tp infusion reduced postoperative ascitic drain output resulting in less frequent percutaneous interventions and reduced hospital stay. Intraoperative hyperlactatemia and symptomatic bradycardia are major concerns. Its use should be restricted to patients with high-volume ascites, and it needs close monitoring during drug infusion. Liver Transplantation 23 1007-1014 2017 AASLD.

The ascites N-glycome of epithelial ovarian cancer patients

Epithelial ovarian cancer (EOC) is worldwide the sixth most lethal form of cancer occurring in women. More than one third of ovarian patients have ascites at the time of diagnosis and almost all of them have it when recurrence occurs. Although its effect on tumor cell microenvironment remains poorly understood, its presence is correlated with bad diagnosis. In previous studies, we proposed a novel glycan-based biomarker for the diagnosis of EOC, which showed an improved sensitivity and specificity at any stage of the disease and an improved discrimination between malignant and benign ovarian tumors. In this work, we report for the first time the N-glycome profiles of ascitic fluid from primary serous EOC patients and compare them with the serum N-glycomes of the same patients as well as of healthy controls. N-Glycans were digested from equivalent amount of ascites and serum from 18 EOC patients and from serum of 20 age-matched controls and measured by MALDI-TOF-MS. Ascites N-glycome showed increased antennarity, branching, sialylation and LewisX motives compared to healthy serum. In addition, a correlation was established between ascites volume and degree of sialylation. SignificanceMalignant ascitic fluid is the build-up of large volumes of fluid in the peritoneal cavity secondary to cancer. At least one-third of ovarian cancer patients develop ascites, a generally voluminous fluid containing cells of tumor origin, in the course of cancer and almost all when recurrence occurs. The proteome of ascites is known to be as complex as that of serum and contains high amount of proteins shed from inflammatory cells as well as from tumor cells. Although many attempts have been made to provide molecular insight into the proteomic and peptidomic content of malignant ascites, no data about the N-glycome of the ascitic fluid fraction from cancer patients has been reported to date.In this study, the N-glycosylation profile of ascites from 20 patients suffering from epithelial ovarian cancer (EOC) was analyzed by MALDI-TOF-mass spectrometry and compared to the pathologically modified N-glycan pattern obtained from serum of the same patients as well as to the pattern of serum from healthy individuals. Significant quantitative differences were observed in the ascites of EOC patients when compared to the serum of healthy subjects. The glycome of ascites shows typical features of inflammatory conditions, what was also found in the serum of patients suffering from EOC when compared to healthy serum. In addition, a correlation was established between ascites volume and degree of sialylation, showing that the high-volume ascites contains a higher amount of sialylated structures than the low-volume ascites.

Molecular profiling and clinical outcome of high-grade serous ovarian cancer presenting with low- versus high-volume ascites.

Epithelial ovarian cancer consists of multiple histotypes differing in etiology and clinical course. The most prevalent histotype is high-grade serous ovarian cancer (HGSOC), which often presents at an advanced stage frequently accompanied with high-volume ascites. While some studies suggest that ascites is associated with poor clinical outcome, most reports have not differentiated between histological subtypes or tumor grade. We compared genome-wide gene expression profiles from a discovery cohort of ten patients diagnosed with stages III-IV HGSOC with high-volume ascites and nine patients with low-volume ascites. An upregulation of immune response genes was detected in tumors from patients presenting with low-volume ascites relative to those with high-volume ascites. Immunohistochemical studies performed on tissue microarrays confirmed higher expression of proteins encoded by immune response genes and increased tumorinfiltrating cells in tumors associated with low-volume ascites. Comparison of 149 advanced-stage HGSOC cases with differential ascites volume at time of primary surgery indicated low-volume ascites correlated with better surgical outcome and longer overall survival. These findings suggest that advanced stage HGSOC presenting with low-volume ascites reflects a unique subgroup of HGSOC, which is associated with upregulation of immune related genes, more abundant tumor infiltrating cells and better clinical outcomes.

Hepatic angiosarcoma mimicking sinusoidal obstruction syndrome/venoocclusive disease: a pathologic-radiologic correlation

We present a case of a 63-year-old man with liver dysfunction and biopsy findings of venoocclusive disease (VOD) who, at autopsy, was discovered to have multifocal hepatic angiosarcoma. After double lung transplantation, he initially presented with signs of liver failure and portal hypertension resulting in recurrent high-volume ascites. Clinically, VOD was considered, and tacrolimus was discontinued, due to its known association with VOD. This, however, did not result in clinical improvement, and computed tomography eventually revealed the development of multiple low-attenuating hepatic lesions over the course of several months. Biopsies of the masses and background liver demonstrated changes most consistent with VOD, characterized by sinusoidal congestion affecting the centrilobular areas with associated hepatocyte atrophy and dropout. A reticulin stain highlighted deposition of reticulin fibers within the sinusoids and central veins. Scattered sinusoidal atypical cells were identified; however, a definitive diagnosis of malignancy was not possible. He eventually passed away because of complications of liver disease. At autopsy, there were multiple firm, red-brown masses identified throughout both hepatic lobes. Upon histologic review, the masses were shown to be angiosarcoma. Away from the tumor, the liver also demonstrated features of VOD. It is likely that the histologic appearance of VOD in the background liver probably represents secondary changes due to injury to the hepatic sinusoids by the primary malignancy. We conclude that it is necessary to consider the possibility of unsampled vascular malignancy when hepatic masses are identified on imaging and histology is consistent with VOD.

Chylous ascites due to signet ring cell gastric adenocarcinoma

"Chylous ascites is a rare presentation of peritoneal effusion. The signet ring cell gastric adenocarcinoma is also relatively rare presentation of gastric cancer. We present a quite rare case of chylous ascites associated with signet ring cell gastric adenocarcinoma. a 47-years-old Caucasian man presented to our emergency department with abdominal distention. The abdominal ultra-sound showed high volume ascites and the diagnostic paracentesis revealed milk-like peritoneal fluid rich in triglycerides. He was underwent to medium chain triglycerides based diet, total parenteric diet and treatment with somatostatin without response. Due to presented digestive hemorrhagic events, upper digestive endoscopy was performed and revealed signet ring cells gastric adenocarcinoma on biopsy. The patient died in disseminated intravascular coagulation context. chylous asicites is a rare presentation of ascites and it may be associated with abdominal neoplasm. The prompt diagnosis is important for optimize the etiology evaluation and therapeutically approach."

Update on liver MRI at 3T

3T MRI of the liver has become widely available and is routinely utilized in the clinical setting, but published scientific data comparing 1.5T with 3T is limited. Theoretically, higher field strength is desirable in body imaging owing to an increase in signal-to-noise ratio, greater spectral separation, the potential for faster scan times and improved tissue contrast on dynamic contrast-enhanced MRI. Yet, there are specific challenges to body imaging at 3T. Despite the theoretical benefits of higher field strength, tradeoffs are often required to achieve optimal image quality, for example increasing bandwidth to reduce chemical shift artifact and thereby sacrificing signal-to-noise. In some instances, such as pregnancy or in the setting of high-volume ascites, 1.5T field strength may be preferred. This article highlights the challenges and necessary adjustments required to effectively image the liver at 3T, while discussing recent studies and ongoing advances in high-field imaging as it impacts the diagn...

400 Met as a potential therapeutic target in basal-like breast cancer

Epithelial ovarian cancer (EOC) is worldwide the sixth most lethal form of cancer occurring in women. More than one third of ovarian patients have ascites at the time of diagnosis and almost all of them have it when recurrence occurs. Although its effect on tumor cell microenvironment remains poorly understood, its presence is correlated with bad diagnosis. In previous studies, we proposed a novel glycan-based biomarker for the diagnosis of EOC, which showed an improved sensitivity and specificity at any stage of the disease and an improved discrimination between malignant and benign ovarian tumors. In this work, we report for the first time the N-glycome profiles of ascitic fluid from primary serous EOC patients and compare them with the serum N-glycomes of the same patients as well as of healthy controls. N-Glycans were digested from equivalent amount of ascites and serum from 18 EOC patients and from serum of 20 age-matched controls and measured by MALDI-TOF-MS. Ascites N-glycome showed increased antennarity, branching, sialylation and LewisX motives compared to healthy serum. In addition, a correlation was established between ascites volume and degree of sialylation.Malignant ascitic fluid is the build-up of large volumes of fluid in the peritoneal cavity secondary to cancer. At least one-third of ovarian cancer patients develop ascites, a generally voluminous fluid containing cells of tumor origin, in the course of cancer and almost all when recurrence occurs. The proteome of ascites is known to be as complex as that of serum and contains high amount of proteins shed from inflammatory cells as well as from tumor cells. Although many attempts have been made to provide molecular insight into the proteomic and peptidomic content of malignant ascites, no data about the N-glycome of the ascitic fluid fraction from cancer patients has been reported to date.In this study, the N-glycosylation profile of ascites from 20 patients suffering from epithelial ovarian cancer (EOC) was analyzed by MALDI-TOF-mass spectrometry and compared to the pathologically modified N-glycan pattern obtained from serum of the same patients as well as to the pattern of serum from healthy individuals. Significant quantitative differences were observed in the ascites of EOC patients when compared to the serum of healthy subjects. The glycome of ascites shows typical features of inflammatory conditions, what was also found in the serum of patients suffering from EOC when compared to healthy serum. In addition, a correlation was established between ascites volume and degree of sialylation, showing that the high-volume ascites contains a higher amount of sialylated structures than the low-volume ascites.

Use of orlistat to treat chylous ascites: a case report

Orlistat, a potent lipase inhibitor that prevents fatty acid absorption, has been used effectively in the management of obesity. We present the first case describing the use of orlistat to treat chylous ascites. A 47 year-old Hispanic man with hepatitis C and alcohol cirrhosis was admitted with severe abdominal distention and dyspnea. He had a history of refractory ascites requiring serial paracentesis. Due to diabetes-associated renal insufficiency, he was on minimal diuretics. He was afebrile and stable. The physical exam demonstrated stigmata of chronic liver disease, decreased right breath sounds, and tense ascites. Blood tests showed a baseline chronic anemia, total bilirubin 2.2, INR 1.4, and albumin 1.4. Previously the ascitic fluid was clear with a high SAAG. On this admission however, the ascitic fluid was milky, pink-colored with triglyceride 585, total protein 0.7, albumin <0.1, RBC 8850, and WBC 300. He was concurrently found to have a new large right pleural effusion that was also milky in appearance with triglyceride 691. A nuclear medicine macroaggregated albumin study confirmed the chylothorax to be of hepatic origin. Extensive testing of the ascitic and pleural fluids showed negative cytology and cultures, including AFB. A colonoscopy and bone marrow biopsy were also normal. The chylous ascites and chylothorax were attributed to cirrhosis, and the patient was placed on a low-fat diet supplemented by medium chain triglycerides (MCT) oil. The chylous ascites and chylothorax responded poorly, however. It was later determined to be due to dietary noncompliance. In an effort to limit his dietary fat intake, orlistat was then started with each meal. The MCT oil was taken independently. After orlistat supplementation, the chylous ascites and chylothorax both resolved. Although the high volume ascites and hydrothorax persisted, the ascitic triglyceride fell to 66 and pleural effusion triglyceride fell to 247. After placement of a TIPS shunt, the ascites and pleural effusion completely resolved. Chylous ascites can have various causes, including cirrhosis. Irrespective of the cause, the traditional management has been a low-fat diet supplemented with MCT oil. As our case shows, however, this can be difficult to implement successfully even in a hospital setting. We demonstrated that in this situation orlistat can be used effectively as an aid to achieve a truly low-fat diet.