Background: Congenital chylous ascites is a rare condition that constitutes a challenge for the physician. It is defined as the accumulation of chyle into the peritoneal cavity in infants younger than 3 months. This condition is often refractory to therapy and it is responsible for serious malnutrition and immunological deficiency because of the loss of proteins and lymphocytes. Material and methods: Four cases of congenital neonatal chylous ascites, were treated by our staff during the last two years.
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Successful management of chylous ascites with total parenteral nutrition and octreotide in children. Department of Pediatric surgical oncology. Children's Hospital of Chongqing Medical University. Purpose: To evaluate the effects of total parenteral nutrition and octreotide on pediatric patients with chylous ascites post-operative. Methods: Four patients were diagnosed with chylous ascites from nov to nov Total parenteral nutrition and octreotide was administered to 2 patients, while the other two only received fasting and total parenteral nutrition.
All patients had persistent peritoneal drainage, with the quantity and quality of drainage fluid observed daily. Results: Two patients who received somatostatin therapy completely recovered within 7d without any recurrence while on a normal diet. The other two patients who only received fasting and total parenteral nutrition was cured d after therapy. Conclusion: Total parenteral nutrition along with octreotide can relieve the symptoms and close the chyle leakage in patients with chylous ascites rapidly.
It seems to be an effective therapy available for the treatment of chylous ascites. Key words: Chylous ascites. Total parenteral nutrition. Parece ser un tratamiento eficaz para la ascitis quilosa. Palabras clave: Ascitis quilosa. Chylous ascites is the extravasation of milky chyle rich in triglycerides into the peritoneal cavity. Postoperative chylous ascites is not so rare in the pediatric population.
They more commonly occur after retroperitoneal operations 1. Chylous ascites may lead to additional morbidity in pediatric patients.
Conservative treatment of chylous ascites, recommended in most patients, involves paracentesis, a medium chain triglyceride MCT based diet, total parenteral nutrition TPN.
Although chylous leak can be corrected by surgical interventions, surgery is invasive and requires expertise and is associated with significant mortality 2.
Therefore, a pharmacologic agent that closed of the leak seemed to be very valuable in the treatment of chylous effusion. The use of somatostatin and its analogs octreotide has recently been introduced into the management of iatrogenic chylothorax and chyloperitoneum in children 3, 4 , however this treatment was still with little experience in world literature, especially in pediatric population. Here we report on our successful use of persistent peritoneal drainage, TPN as well as octreotide in treatment of 4 cases of chylous ascites.
Four patients with chylous ascites were included in this study from November to Nov All patients developed chylous ascites after surgery. There was no congenital chylous ascites. Patient 1 was a 4 month infant with retroperitoneal teratoma, and developed chylous ascites 1 week after tumor resection. Two patients patient 2 and 4 with retroperitoneal neuroblastoma were diagnosed as chylous ascites 1 month and 2 weeks after surgery respectively. Patient 2 was operated in another hospital, and administrated to our hospital due to abdominal distention one month after surgery.
Patient 3 was a celiac Burkitt lymphoma with ileocecus mesentery lymph node enlargement, and chylous ascites was observed 10 day after ileocecus mesentery lymphadenectomy.
The diagnosis was confirmed by analyzing the ascites fluid obtained through peritoneal drainage. Table I shows the clinical features and laboratory findings of ascites samples from 4 patients. As soon as the diagnosis was confirmed, every patient was put in fasting state and received fluid therapy to correct the disturbance of water, electrolytes and acid-base. A single lumen central venous catheter was inserted into the peritoneal cavity for continuous drainage in 1 patients patient 2 , while peritoneal cavity drainage tubes inserted during the operation were reserved in the other 3 patients.
The quality and quantity of drainage fluid were monitored daily. Then TPN as administered to patients at gradually increasing dose. During TPN administration, liver function and blood fat were monitored every week for all patients. Patient 1 and 3 received continuous intravenous infusion of the octreotide Sandostatin, Novartis Pharma AG , at an initial dose of 1.
Necessary supportive treatments, such as albumin, diuretics and antibiotics were given to the patients individually during the therapy. Finally, any adverse effects that could be attributed to octreotide were also noted. Figure 1 to 4 shows the change of drainage volume, the duration of TPN and octreotide therapy of 4 patients. Of the two patients with chylous ascites who received octreotide therapy, peritoneal drainage volume were decreased dramatic after octreotide administration, and completely recovery within 7 d, while patients who only received TPN was cured d after therapy.
Once the peritoneal drainage was zero or was proved non-chylous ascites, TPN and octreotide dose would diminish gradually along with the recovery of oral low fat diet. CT follow-up examinations did not reveal the presence of ascitic fluid. Follow-up study found no recurrence in these patients while on normal diet. And no side effect was observed at follow-up. The main etiology of chylous ascites in children is congenital.
Other causes of chylous ascites in children are either idiopathic or obstructive lesions caused by malrotation, intussusception, incarcerated hernia, lymphan-gioma, blunt trauma, liver disease, and tuberculosis 5. However, chylous ascites is considered an uncommon complication after abdominal surgery.
The loss of lymphatic fluid causes hypoal-buminemia, hydroelectrolyte alterations, coagulation and immunodeficiency with important involvement of clinical condition of the child and increased morbidity and mortality 7.
There are conservative and surgical treatments for chylous ascites, and the latter is usually indicated after failure of conservative treatment after two to three weeks 8. However, such procedure is limited by anatomic variations of the duct location, as well as difficulty to identify the drainage site 9. The management of chylous ascites after surgery comprises a spectrum of interventions, from dietary management to exploratory laparatomy.
Furthermore, TPN restores nutritional deficits and balances metabolic impairments imposed by chylous ascites and repeat sessions of paracentesis. So fasting and TPN are essential in nonoperative management of chylous ascites Surgical ligation of the chylous fistula is recommended when conservative treatment fails.
In our study, patient 2 and 4 who only received fasting and TPN recovered completely between d. Octreotide, a synthetic, long-acting somatostatin analogue, has been suggested as a therapeutic agent in the management of several clinical disorders. By inhibiting the secretion of some pituitary and gastrointestinal hormones, octreotide can increase splanchnic arteriolar resistance, reduce gastrointestinal flow and, consequently, the lymph flow However, the clinical experience with octreotide is limited in pediatric patients.
A somatostatin analog was first used for postoperative chylous ascites in a pediatric patient in , as reported by Lam et al 4.
Reports of successfully management with octreotide for pediatric chylothorax and chylous ascites were increasing in recent ten years 9, , the effect were promising which reducing recovering time and the potential need for surgical intervention and without obviously side effects 8 , however, there were few reports of octreotide treatment for chylous ascites post-operation. In our series, all 4 patients presented with chylous ascites after surgery, 2 out of 4 patients were successfully treated with octreotide.
The output of drainage tubes were persistent, even increased, in two patients although they were fasting for days but resolved immediately after the use of octretide. Given the observed rapid resolution of chylous effusion with the octreotide administration, it appears that octreotide infusion rather than natural healing was responsible for the closure of chyle leakage, though the mechanism still needs further investigation. When comparing the two patients who only received fasting and TPN, octreotide therapy with TPN obviously shortened the curative time, decreased the treatment cost and no significant side effect was observed.
Side effects of octreotide relate to reduced sperm motility and intestinal secretion: hypertension, malabsorption, nausea, flatulence, hepatic dysfunction and hyperglycemia However, there are few side effects observed in literature reports, as well as our follow-up of patients using octreotide.
Because octreotide interferes with blood glucose regulation, close monitoring of blood glucose and gradual tapering of octreotide is recommended. Oral or enteral MCT-rich diet accompanying the adequate draining was recommend in some study 19 , MCT-rich diet not only provides adequate nutrition, but also decreases the lymph leak in order to support healing.
However, if lymphatic effusion does not decrease, oral or enteral feeding should be stopped and TPN should be initiated. In our series, all patients put in fasting state and received TPN until the drainage was zero or was proved non-chylous ascites. All patients began with low-fat or no-fat MCT-rich diets and transited to normal diet gradually. No recurrence was observed in all patients.
The results found in our study are encouraging with respect to drug safety, and favorable outcome in the treatment of chylous ascites. Although lack of prospective randomized study, On the basis of previous reports and our experience, we suggests that TPN with octreotide should be considered as a possible prior therapeutic option in managing pediatric post-operative chylous ascites.
Further studies of multicenter clinical trials involving more patients to compare the effectiveness and cost between this therapy and the others are suggested. The diagnosis and management of postoperative chylous ascites. J Urol ; 2 Pt 1 : Aetiology and treatment of chylous ascites. Br J Surg ; 79 11 : Octreotide to treat postoperative chylothorax after cardiac operations in children. Ann Thorac Surg ; 72 5 : Initial experience with octreotide in the pediatric population.
Am J Ther ; 8 6 : Chylous ascites in infants and children. Surgery ; 93 3 : Chylous ascites: CT and ultrasound appearance.
Abdom Imaging ; 20 2 : Sahin Y, Aydin D. Congenital chylothorax treated with octreotide. Indian J Pediatr ; 72 10 : Octreotide infusion for the treatment of chylothorax in pediatric cardiac intensive care unit. Anadolu Kardiyol Derg ; 5 4 : Use of octreotide in the treatment of chylothorax and chyloperitoneum. Arq Bras Cardiol ; 97 2 : e Chylous ascites: a collective review. Surgery ; 5 :
Ascitis quilosa por maltrato
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. La ascitis quilosa es la acumulacion de liquido quiloso en la cavidad peritoneal. Puede ser primaria defectos congenitos o secundaria obstruccion,traumatismos, etc. Es nuestro objetivo poner en conocimiento una forma poco comun de presentacion de sindrome de maltrato infantil. Se presenta una nina de un ano de edad, que ingreso a nuestro hospital por presentar un cuadro de maltrato infantil con distension abdominal.
Diagnosis and management of congenital neonatal chylous ascites