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
ansaraya@yahoo.com
Expert in field

Sanchit Singh, MD, DrNB

Consultant, Max Super Speciality Hospital Vaishali

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
 snchtsingh05@gmail.com
Dynamic, active and academically oriented

Opposed Reviewers:

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
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
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- drkapilsharma83@gmail.com
Telephone no- +917023176653
No financial Disclosure

Co-authors

Faisal Rasheed
MD (Internal Medicine)
Senior Registrar Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
Email Id- dr.faisalrasheed@gmail.com
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- vasudha_mamc04@gmail.com
No financial Disclosure

Mumina Ramzan
MD (Internal Medicine)
Senior Registrar Department of Gastroenterology
Batra Hospital and Medical Research Centre, New Delhi, India
Email Id- dr.mumina21@gmail.com
No financial Disclosure
Manuscript Click here to view linked References

1
2
3
4
5
6
7 Conservatively Managed Chylous Ascites in Cirrhosis – A Case Series Formatted: Centered
8
9 Faisal Rasheed1, Kapil Sharma1, Vasudha Goel1, Mumina Ramzan1
10 1 – Batra Hospital and Medical Research Centre New Delhi

11
12
13 ABSTRACT Formatted: Left
14 Introduction– Chylous ascites is a rare condition in decompensated cirrhotic patients
15 characterized by accumulation of milky fluid, rich in triglycerides. These patients generally
present with multiple comorbidities, making them unsuitable for treatment options like TIPS
16
(Transjugular Intrahepatic Portosystemic Shunts). Chylous ascites is a refilling ascites
17 requiring frequent paracentesis, leading to increased morbidity, hospital admission and cost.
18 These patients do not respond to high protein, salt restricted diet and diuretics. Limited data is
19 available on use of subcutaneous (s/c) octreotide (OCT) and low fat diet (LFD) in these
20 patients.
21 Methods – We prospectively observed 3 patients who presented with tense chylous ascites
22 who had undergone multiple large volume paracentesis. They were on highest tolerable dose
23 of diuretics, compliant to salt restriction and had not undergone TIPS either due to
24 contraindications or denial of consent. These patients were evaluated for malignancy,
25 infection (tubercular), pancreatitis, and cardiac disease. They were advised low fat diet and
26 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
27
observed for total period of 7 months.
28 Results – Patients advised with LFD and OCT in combination with standard medical
29 treatment showed decreased need for paracentesis and had well controlled ascites. These
30 patients showed resolution of chylous ascites in the first month of starting treatment and
31 effect persisted even after stopping octreotide.
32 Conclusion – Chylous ascites treated with LFD and OCT showed decreased need for LVP
33 and persistence of effects even after stopping OCT. It should be considered as a first line
34 treatment for refilling chylous ascites in patients not fit for TIPS or Liver Transplantation.
35
36 Keywords – Chylous ascites, octreotide, Low Fat Diet, Paracentesis, cirrhosis
37
38 Introduction – Chylous ascites is accumulation of milky, triglyceride rich fl fluid in the Formatted: Font: Bold
peritoneal cavityrich in triglyceride. Among patients with atraumatic chylous ascites,
39
malignancy is the most common cause, followed by cirrhosis, and tuberculosis [1]1. In a
40 developing country like India, tTuberculosis accounts for a significantly high proportion of
41 patients. The pPrevalence of chylous ascites in cirrhotics is only 0.5% - 1% [2]. In cirrhosis Formatted: Not Superscript/ Subscript
42 lymphatic flow is increased, along with the number and density of lymph vessels, leading to s
43 is increased and lymphatic oversaturation and flow dysfunction occurs [3-5]3–5. A triglyceride
44 concentration of more than 200 mg/dL in ascitic fluid is needed for the diagnosis 1. Chylous
45 ascites in cirrhotics is refilling ascites, that needs multiple Large Volume Paracentesis (LVP)
46 despite being on salt restricted diet and maximum tolerable dose of diuretics. Need for
47 multiple LVP and high dose diuretics causes circulatory dysfunction and acute kidney injury
48 (AKI), adding to the increasing morbidity, need for hospitalization and mortality.
49 Transjugular Intrahepatic Portosystemic Shunt (TIPS) has been found to be an effective
option for refilling ascites, needing multiple, frequent LVP. Though not all patients are
50
candidates for TIPS, non invasivenon-invasive options like Low Fat Diet (LFD) and
51 Octreotide have not been largely studied and theirre long termlong-term outcomes are not
52
53
54
55
56
57
58
59
60
61
62
63
64
65
 1
2
3
4
5
6
7 reported. Only few case reports have been published regarding use of octreotide in chylous
8 ascites in cirrhotics [6,7]6,7
9
10 Case Series Formatted: Font: Bold
11
12 Case 1 – A 45 year old45-year-old male, diagnosed with decompensated alcoholic cirrhosis Formatted: Font: Bold
13 sincefor two years, with history of prior hepatic encephalopathy, presented with worsening of
14 ascites which was earlier stable on diuretics and salt restricted diet. For this, he underwent 4
15 large volume paracentesisparacentesis with drainage of 20 litres of ascites one month before
presentation. Patient was admitted, and evaluated for worsening of ascites. Investigations
16
showed Hemoglobin 9.3 mg/dL, serum creatinine 2.7 mg/dL, and serum albumin of 2.3 g/dL.
17 In view of AKI patient was started on serum albumin 1g/kg on day 1 and day 3. Diagnostic
18 ascitic tap was performed which showed high SAAG ( Serum(Serum Ascites Albumin
19 Gradient) ascites, and noand no evidence of tuberculosis / SBP (Spontaneous Bacterial
20 Peritonitis) and high triglyceride levels (369 mg/dl )dL) (table 1). His serum creatinine
21 improved by day 4. In view of chylous ascites patient was started on Low Fat diet, and
22 octreotide (100 mcg, subcutaneously eight hourlyt.i.d). PNeed for paracentesis decreased, and
23 patient needed only one LVP after starting treatment and cleared triglyceride in the first
24 month of treatment ( table(table 2). Patient was continued on treatment for 3 months, after
25 which octreotide was stopped and patient was continued on LFD and observed for next 4
26 months. During this period, he showed controlled ascites on diuretic and LFD therapy
needing only one LVP, with no relapse of chylous ascites.
27
28 Case 2 – Our second patient was a 65 year old65-year-old long standing diabetic diagnosed Formatted: Font: Bold
29 with chronic liver disease on evaluation for ascites 2 months back. Patient was started on
30 diuretics and underwent multiple LVP ,LVP, and presented to us with worsening ascites. His
31 blood investigations showed moderate anemia (Hb- 7.4g/dL), serum creatinine of 1.1mg/dL,
32 serum albumin 2.8g/dL. Ascitic fluid analysis showed high SAAG ascites, triglyceride value
33 of 843mg/dLl and no evidence of tuberculosis/SBP. Triple phase CT abdomen showed partial
34 thrombus in main portal vein (table 1). Patient was started on octreotide (100 mcg s/c eight
35 hourlyt.i.d.) and LFD. Patient showed some improvement in ascites formation by 1 month,
36 which significantly improved by 3 months. Octreotide was stopped after 3 months of
37 treatment and patient was followed for a total of 7 months. During this period patient
38 underwent single paracentesis of 2.5 liters and was controlled on diuretic and low fatlow-fat
diet (table 2).
39
40
41
42
43 Formatted: Font: Bold
44 Table 1 – Patients baseline characteristics
45 Case 1 Case 2 Case 3
46 Hemoglobin (g/dL) 9.3 7.4 10.6
47 Total leucocyte count (/µL) 5880 7260 5690
48
49 Platelet (103/µl) 140 95 122
50 Urea / creatinine (mg/dL) 68/2.7 18/1.1 67/1.9
51
52 Total bilirubin (mg/dL) 1.76 1.09 2.1
53
54
55
56
57
58
59
60
61
62
63
64
65
 1
2
3
4
5
6
7 AST/ALT/ALP (IU/L) 51/35/178 61/53/71 34/28/67
8 Serum albumin (g/dL) 2.3 2.8 2.6
9 AFP (ng/mL) 2.26 2.2 3.2
10 PT (sec)/INR 14.2/1.24 16.1/1.45 15.1/1.39
11 Serum ammonia (µg/dL) 57 291 109
12
13 Ascitic Fluid
14
TLC (/µL)/ DLC 150 / N20%L50 180 / N37%L63% 280 / N25%L75%
15
16 Protein / Albumin (mg/dL) 2.4 / 0.9 2.13 / 1 2.4/0.8
17
18 ADA (U/L) 4.9 2.6 3.1
19
20 Triglyceride (mg/dL) 369 843 626
21
22 LDH (U/L) 127 193 110
23
24 Gene X-pert MTB Negative Negative Negative
25
26
27 Cytology for malignant cells Negative Negative Negative
28
29 Chest x-ray Normal, no PE Normal, no PE Mild Right side
30 PE
31 Echo Normal LV/RV Normal LV/RV Normal LV/RV
32 function function function
33 CT abdomen (triple phase) Features of CLD, Features of CLD, Features of CLD,
34 no liver SOL no liver SOL. no liver SOL
35 Partial thrombus
36 in MPV
UGI endoscopy Small EV Post EVL Small EV
37
CTP Score 9 8 10
38
MELD 20 12 19
39
PE – Pleural effusion, LV- left ventricle, RV – right ventricle, CLD- Chronic liver disease,
40
SOL- Space occupying lesion, MPV- main portal vein, EVL- Esophageal Variceal Ligation.
41
42
43 Case 3 – 49 year old49-year-old male patient, diagnosed as decompensated alcoholic liver Formatted: Font: Bold
44 disease, alcohol abstinent, was controlled on diet and diuretic therapy sincefor three years. He
45 developed new onset refilling ascites, and underwent three LVP with drainage of around 15
46 liters of fluid. Ascites was high SAAG low protein, with no evidence of tuberculosis/ SBP/
47 malignancy, and ascitic fluid triglyceride level of 526 mg/dLl (table 1). Patient was advised
48 TIPS, for which consent was denied. He was started on Octreotide (100 mcg s/c eight
49 hourlyt.i.d.) and LFD, following which he underwent one LVP during stay in our hospital.
50 He showed improvement in ascites control, and was discharged after 15 days of hospital stay
on diuretic, LFD and octreotide. He was on same treatment for 3 months after which
51
octreotide was stopped, and LFD – salt restriction and diuretic were continued. He did not
52 need any paracentesis and ascites was controlled during follow up of next 4 months (table 2).
53
54
55
56
57
58
59
60
61
62
63
64
65
 1
2
3
4
5
6
7
8 Table 2 – Clinical events, treatment and follow up Formatted: Font: Bold
9
10 Patient 1 Patient 2 Patient 3 Formatted Table
11 Months Paracentesis Octreotide Paracentesis Octreotide Paracentesis Octreotide
12 (Liters) & low fat (Liters) & low fat (Liters) & low fat
13 diet diet diet
14
15 Month 0 4 (20 L) No 4 (16L) No 3 (15L) No
16 Month 1 1 (6L) Yes 1 (4L) Yes 1 (11L) Yes
17 Month 2 0 Yes 0 Yes 0 Yes
18 Month 3 0 Yes 0 Yes 0 Yes
19 Month 4 0 OCT - / 0 OCT - / 1 OCT - /
20 LFD + LFD + LFD +
21 Month 5 0 OCT - / 1 (2.5L) OCT - / 0 OCT - /
22 LFD + LFD + LFD +
23 Month 6 1 (6L) OCT - / 0 OCT - / 0 OCT - /
24 TG- 86 LFD + LFD + LFD +
25 Month 7 0 OCT - / 0 OCT - / 0 OCT - /
26 LFD + LFD + LFD +
27 TG- Triglyceride, OCT – Octreotide, LFD- Low Fat Diet.
28
29 Discussion – Liver disease patients with chylous ascites need recurrent large volume Formatted: Font: Bold
30 paracentesis, ultimately requiring TIPS. Patients included in this case series have not
31 undergone TIPS or. They did not undergo liver transplantation either due to financial
32 constraints or lack of donor unavailability. or financial constraint. These patientThese
33 patients were offered octreotide with LFD, and diuretics and stoppage of beta blocker
variceal and management of varices with variceal ligation. Beta blockers were withheld in all
34
cases. After three months of treatmenttreatment, they showed significant improvement in
35 control of ascites, which was maintained not only during treatment period but also during the
36 follow up periodup of four months. This is indirectly proof of conceptshowed that octreotide
37 and LFD not only decreases lymphatic production resulting in ascites control, but also
38 corrects lymphatic dysfunction, resulting in a long termlong-term effect. Further larger
39 studies are, however, needed to confirm these findings.
40
41 Conclusion – Combination therapy with lLow fat diet and octreotide yielded goodshowed an Formatted: Font: Bold
42 improvement in control of chylous ascites, resulting inand decreased need for large volume
43 paracentesis. This intervention proposed to decrease the lymphatic production and flow. In Formatted: Font color: Yellow
44 view of hypothesis of lymphatic rupture due to increased flow in portal hypertension patients Formatted: Font color: Red
[8], continuation of treatment beyond resolution of chylous ascites results in healing of
45 Formatted: Font color: Yellow
ruptured lymphatic vessels. One of the hypotheses elucidating the pathogenesis of chylous
46 ascites is increased lymphatic flow in portal hypertension patients, leading to lymphatic
47 rupture. In our case series, we continued to give octreotide with LFD despite clinical
48 resolution of ascites for two more months, following which we observed prolonged remission
49 in the follow up period. A plausible explanation for this can be decreased lymphatic
50 production and flow, which would have promoted lymphatic healing, in turn leading to This
51 leads to persistence of the beneficial effect s even afterbeyond stoppage of treatment. Therapy
52 with octreotide and LFD can prove to be useful, especially in resource limited settings.
53
54
55
56
57
58
59
60
61
62
63
64
65
 1
2
3
4
5
6
7 Larger studies, to reinforce this preliminary evidence, can help to bring about a change in
8 clinical practice.Low fat diet and Octreotide is a better alternative in setting of absence of
9 expertise in TIPS or patients not fit for the procedure and large studies are needed.
10
11 References – Formatted: Font: Bold
12 Formatted: Font: Bold
13 1. Al-Busafi SA, Ghali P, Deschênes M, Wong P. Chylous Ascites: Evaluation and
14 Management. ISRN Hepatol. 2014;2014:1-10. doi:10.1155/2014/240473
15 2. Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic
16 approach and current management of chylous ascites. Aliment Pharmacol Ther.
17 2017;46(9):816-824. doi:10.1111/apt.14284
18 3. Kumar R, Anand U, Priyadarshi RN. Lymphatic dysfunction in advanced cirrhosis:
19 Contextual perspective and clinical implications. World J Hepatol. 2021;13(3):300-
20 314. doi:10.4254/wjh.v13.i3.300
21 4. Vollmar B, Wolf B, Siegmund S, Katsen AD, Menger MD. Lymph Vessel Expansion and
22 Function in the Development of Hepatic Fibrosis and Cirrhosis. Vol 151.; 1997.
23 5. Tanaka M, Iwakiri Y. The Hepatic Lymphatic Vascular System: Structure, Function,
Markers, and Lymphangiogenesis. CMGH. 2016;2(6):733-749.
24
doi:10.1016/j.jcmgh.2016.09.002
25
6. Zhou DX, Zhou HB, Wang Q, Zou SS, Wang H, Hu HP. The effectiveness of the
26
treatment of octreotide on chylous ascites after liver cirrhosis. Dig Dis Sci.
27
2009;54(8):1783-1788. doi:10.1007/s10620-008-0566-6
28
7. Berzigotti A, Magalotti D, Cocci C, Angeloni L, Pironi L, Zoli M. Octreotide in the
29
outpatient therapy of cirrhotic chylous ascites: A case report. Digestive and Liver
30 Disease. 2006;38(2):138-142. doi:10.1016/j.dld.2005.05.013
31
32 1. Al-Busafi SA, Ghali P, Deschênes M, Wong P. Chylous Ascites: Evaluation and Formatted: Indent: Left: 0", First line: 0"
33 Management. ISRN Hepatol. 2014;2014:1-10. doi:10.1155/2014/240473
34 2. Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic
35 approach and current management of chylous ascites. Aliment Pharmacol Ther.
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):300-314.
39 doi:10.4254/wjh.v13.i3.300
40 4. Vollmar B, Wolf B, Siegmund S, Katsen AD, Menger MD. Lymph Vessel Expansion and
41 Function in the Development of Hepatic Fibrosis and Cirrhosis. Vol 151.; 1997.
42 5. Tanaka M, Iwakiri Y. The Hepatic Lymphatic Vascular System: Structure, Function,
43 Markers, and Lymphangiogenesis. CMGH. 2016;2(6):733-749.
44 doi:10.1016/j.jcmgh.2016.09.002
45 6. Zhou DX, Zhou HB, Wang Q, Zou SS, Wang H, Hu HP. The effectiveness of the
46 treatment of octreotide on chylous ascites after liver cirrhosis. Dig Dis Sci. 2009;54(8):1783-
47 1788. doi:10.1007/s10620-008-0566-6
48 7. Berzigotti A, Magalotti D, Cocci C, Angeloni L, Pironi L, Zoli M. Octreotide in the
49 outpatient therapy of cirrhotic chylous ascites: A case report. Digestive and Liver Disease.
50 2006;38(2):138-142. doi:10.1016/j.dld.2005.05.013
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Credit Authorship Contribution Statement

Faisal Rasheed: Conceptualization, Methodology, Data curation,

Writing- Original draft preparation. Mumina Ramzan : Visualization,
Investigation. Vasudha Goel: Writing- Reviewing and Editing.