EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Chylous ascites after a liver transplant is a rare complication of surgery. We report a 11-month-old girl with biliary atresia who was presented with chylous ascites after a liver transplant. On the seventh day after surgery, while being fed, chylous ascites was observed. Besides fasting and diuretics, total parenteral nutrition and somatostatin analogue (octreotide) were initiated. Chylous ascites resolved in 3 weeks. Abdominal distention recurred 1 week later; fasting and total parenteral nutrition, combined with octreotide, were administered again for 2 more weeks. Thereafter, enteral feeding was started without any complications.

Key words : Chylous ascites, Liver transplant, Octreotide

Collection of triglyceride-rich lymph fluid in the abdomen is defined as chylous ascites. Abdominal lymphatic system failure caused by congenital malformations, abdominal trauma, tumors, peritoneal bands, generalized lymphangiomatosis, and abdominal surgery can lead to chylous ascites. Demonstration and analysis of milky ascitic fluid are diagnostic for chylous ascites. Characteristics of chylous ascites are a high protein content, an elevated triglycerides greater than 2.2 mmol/L, and lymphocytosis of the fluid.¹ Steinemann and associates reported that liver cirrhosis leads to atraumatic chylous ascites in 11% of all adult patients.² They stated that increased intra-abdominal pressure may result in intra-abdominal leakage of lymphatic fluid.² Also, chylous ascites has been reported as a rare complication after liver transplant. We report an infant who presented with chylous ascites after a liver transplant, who was treated with somatostatin analogue (octreotide).

A 11-month-old girl with biliary atresia who underwent a Kasai procedure was referred to our hospital for a liver transplant. She underwent a living-related left lateral liver transplant. On the seventh day after surgery, when she began to feed, ascites was observed. Biochemical analysis of the fluid was compatible with chylous ascites. Cholesterol level of the fluid was 0.13 mmol/L (serum 3.1 mmol/L), triglyceride level was 4.3 mmol/L (serum 1 mmol/L), white blood count was 210/mm³, and her albumin level was 5 g/L (serum 41 g/L). Results of the fluid culture were negative. Results of the analysis of amylase and lipase levels were normal. Enteral feeding was stopped and besides diuretics, total parenteral nutrition (TPN) and octreotide (60-100 mcg/h IV infusion rate) were initiated. Octreotide infusion replaced by subcutaneous injection in dose 2 × 100 mcg owing to hyperglycemia on the third day of therapy. After 3 weeks, chylous ascites resolved, and she was fed with semi-elemental diet (Pepti-Junior, Cow & Gate, Nutricia Ltd, Trowbridge Wiltshire, Australia). Ultrasonography revealed minimal fluid in abdomen, and she was discharged with subcutaneous octreotide injections. She was rehospitalized 1 week later with fever, pneumonia, and abdominal distention. Percutaneous drainage revealed milky ascitic fluid. Triglyceride level of the fluid was 7.8 mmol/L (serum 1 mmol/L). The chylous fluid disappeared within 2 weeks under TPN and fasting combined with octreotide therapy. Ascitic fluid did not recur with enteral feeding. We stopped octreotide after 2 weeks. At the time of this writing, she has been followed up with no complaints for 6 months.

Abdominal lymphatic vessels injury during removal of the liver, adhesion, or compression of the lymphatic vessels may cause chylous ascites after a liver transplant.^3,4 Chylous ascites may develop 1 to several weeks or months after a lymphatic injury.⁴ Usually, chylous ascites will be symptomatic after enteral feeding. Yılmaz and associates reported chylous ascites in 24 of 516 patients between 5 and 17 days after a liver transplant (mean, 8 d).⁵ The incidence of chylous ascites after a liver transplant is 4.7%.⁵ In this report, ascites before liver transplant, hypoalbuminemia, LigaSure vessel sealing system (LVSS; Valleylab, Boulder, CO, USA) suture ligation for perihepatic dissection were the risk factors for chylous ascites.⁵ Our patient’s milky ascites occurred after initiating enteral feeding the seventh day after surgery.

Treatment of chylous ascites includes low-fat, high-protein diet supplemented with medium-chain triglycerides, and TPN to decrease lymph flow and facilitate healing of the lymph vessel injury. Repeat paracentesis is indicated only if abdominal distention causes respiratory distress. Also, octreotide and diuretics may be chosen for rapid healing.⁶ Peritoneovenous shunting, insertion of a transjugular intrahepatic portosystemic shunt, and surgical ligation of the injured lymphatic vessel are the surgical options for chylous ascites.¹ Fasting and TPN, can decrease lymphatic flow in thoracic duct from 220 mL/kg per hour to 1 mL/kg per hour.^1,3 Resolution varies between 10 and 63.5 days.^6,7 Total parenteral nutrition and octreotide shortened resolution time.⁶ Treatment of the present case included fasting, TPN, and somatostatin analogue for 3 weeks. A semi-elemental diet was begun the fourth week of therapy. After the patient has used subcutaneous octreotide and semi-elemental diet at home for 1 week, she admitted to hospital with abdominal distension and respiratory distress. Ascites was milky despite the semi-elemental diet and octreotide treatment. Fasting, and TPN were applied besides octreotide. Ascitic fluid was not shown on abdominal ultrasonography after 2 weeks of the TPN, fasting, and octreotide. Chylous ascites completely resolved in 50 days. Huang and associates reported 2 of 4 patients treated in 10 days with somatostatin and appropriate nutrition.⁸ It is not clear how somatostatin heals chylous ascites. It ensures time for healing of the lymphatic vessel by reducing intestinal blood flow and indirectly by decreasing the lymphatic flow.⁶ Intestinal activity, fat absorption, secretions of the intestine, and exocrine pancreas are diminished by somatostatin.⁸ In conclusion, chylous ascites after a liver transplant is rarely seen in children and can be effectively managed by fasting, parenteral nutrition, and octreotide.

Volume: 12 Issue: 1 March 2014 - Supplement - 1

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