Br. J. Surg. 1992, Vol. 79, November, 1145-1 150
N. L. Browse, N. M. Wilson, F. Russo, H. Al-Hassan and D. R . Allen Department of Surgery, St Thomas’ Hospital, London, UK Correspondence to: Professor N. L. Browse, The Royal College of Surgeons of England,
35-43 Lincoln‘s Inn Fields, London WC2A 3 P N , U K
Aetiology and treatment of chylous ascites A series of 4.5 patients itith chylous ascites has been reviewed. The age at presentation ranged from I to 80 (median 12) years; 23 patients ic’ere aged < 15 years. Thirty-five patients had an abnormality of the ljn7phatics (primary chylous ascites); in the remaining ten, the ascites was secondary to other conditions, principally non-Hodgkin ‘s lymphoma (si..i patients). Tic90 principal mechanisms of ascites formation were identified usirig lymphangiography and inspection at laparotomy: leakage j r o m retroperitoneal megalyniphatics, usuullj9 through a visible ljvnphoperitoneal ,fistula ( 14 patients); and leakage j?om dilated subserosal lymphatics of the small intestine, invariably associated with leaking lacteals causing protein-losing enteropathy (24 patients ). Both sites of leakage \(‘erepresent in a.further.five patients. In the remaining two patients, clijsle was leaking f r o m normal mesenteric l.vmphatics, in one via a ruj7tured mesenteric lymph cyst and in [he other from the site of’ a previous lymph node biopsy. Other associated lymphatic abiiormalities were present in 36 patients, lymphoedema o f the leg being the commonest (26 patients). All patients were initially treated coriservativelj>with dietary maiiipulation: this as the most satisfactory treatment for those irith leaking small bowel 1,vniphatics. Surgery (fktula closure, bolrel resection or insertion of’ a peritoneovenous shunt) was performed iri 30 patients. Closure of’ a retroperitoiieal fistula, when present, b t m the most successful operation, curing seven of the 12patients so treated.
In 1627. Asellius published the first accurate description of vessels in the mesentery of a dog containing a milky white fluid’. Chylous ascites (the collection of chyle within the peritoneal cavity) was first described in 1691 by Morton after performing paracentesis on an 18-month-old boy’. Trauma was recognized as a cause of chylous effusions by 17th-century physicians, but in 1705 M o r t o n recognized the role of other disease processes3. In 1854 Virchow4 described chylous ascites in a new born calf that had suffered a subclavian vein thrombosis. In recent years a number of small series of patients with chylous ascites have been reported5-*, but with little consistency in proposed aetiology, diagnosis or treatment. Because chylous ascites is both uncommon and sometimes subclinical, its prevalence and aetiology are hard to define. Although different pathological processes might be responsible, three principal mechanisms have been proposed’: ( 1 ) direct leakage of chyle through a lymphoperitoneal fistula, nearly always associated with abnormal retroperitoneal lymphatic vessels; ( 2 ) exudation of chyle through the walls of retroperitoneal megalymphatics without a visible fistula; and ( 3 ) exudation (or leakage following rupture) of chyle from dilated lymphatics on the wall ofthe bowel and in the mesentery, caused by obstruction of the lymphatics at the base of the mesentery or in the cisterna chyli and/or thoracic duct. (Protein-losing enteropathy usually accompanies this condition.) The aim of this study was to define the aetiology of chylous ascites and to correlate this with methods and outcome of treatment. The influence of protein-losing enteropathy on prognosis was also investigated.
been excluded from this study because of inadequate documentation. The remaining 45 patients have been reviewed retrospectively. Their median age at presentation was 12 (range 1-80) years: 23 patients were aged < 15 years. The male:female ratio was 1 . 3 : l .
ClinI~~ul pr.ec.enrutioriund iiircstijlutioii Thirty-four patients presented with abdominal distension, 27 with malnutrition and hypoproteinaemia, 21 with dyspnoea and 21 with steatorrhoea (Tub/
N. L. Browse, N. M. Wilson, F. Russo, H. Al-Hassan and D. R . Allen Department of Surgery, St Thomas’ Hospital, London, UK Correspondence to: Professor N. L. Browse, The Royal College of Surgeons of England,
35-43 Lincoln‘s Inn Fields, London WC2A 3 P N , U K
Aetiology and treatment of chylous ascites A series of 4.5 patients itith chylous ascites has been reviewed. The age at presentation ranged from I to 80 (median 12) years; 23 patients ic’ere aged < 15 years. Thirty-five patients had an abnormality of the ljn7phatics (primary chylous ascites); in the remaining ten, the ascites was secondary to other conditions, principally non-Hodgkin ‘s lymphoma (si..i patients). Tic90 principal mechanisms of ascites formation were identified usirig lymphangiography and inspection at laparotomy: leakage j r o m retroperitoneal megalyniphatics, usuullj9 through a visible ljvnphoperitoneal ,fistula ( 14 patients); and leakage j?om dilated subserosal lymphatics of the small intestine, invariably associated with leaking lacteals causing protein-losing enteropathy (24 patients ). Both sites of leakage \(‘erepresent in a.further.five patients. In the remaining two patients, clijsle was leaking f r o m normal mesenteric l.vmphatics, in one via a ruj7tured mesenteric lymph cyst and in [he other from the site of’ a previous lymph node biopsy. Other associated lymphatic abiiormalities were present in 36 patients, lymphoedema o f the leg being the commonest (26 patients). All patients were initially treated coriservativelj>with dietary maiiipulation: this as the most satisfactory treatment for those irith leaking small bowel 1,vniphatics. Surgery (fktula closure, bolrel resection or insertion of’ a peritoneovenous shunt) was performed iri 30 patients. Closure of’ a retroperitoiieal fistula, when present, b t m the most successful operation, curing seven of the 12patients so treated.
In 1627. Asellius published the first accurate description of vessels in the mesentery of a dog containing a milky white fluid’. Chylous ascites (the collection of chyle within the peritoneal cavity) was first described in 1691 by Morton after performing paracentesis on an 18-month-old boy’. Trauma was recognized as a cause of chylous effusions by 17th-century physicians, but in 1705 M o r t o n recognized the role of other disease processes3. In 1854 Virchow4 described chylous ascites in a new born calf that had suffered a subclavian vein thrombosis. In recent years a number of small series of patients with chylous ascites have been reported5-*, but with little consistency in proposed aetiology, diagnosis or treatment. Because chylous ascites is both uncommon and sometimes subclinical, its prevalence and aetiology are hard to define. Although different pathological processes might be responsible, three principal mechanisms have been proposed’: ( 1 ) direct leakage of chyle through a lymphoperitoneal fistula, nearly always associated with abnormal retroperitoneal lymphatic vessels; ( 2 ) exudation of chyle through the walls of retroperitoneal megalymphatics without a visible fistula; and ( 3 ) exudation (or leakage following rupture) of chyle from dilated lymphatics on the wall ofthe bowel and in the mesentery, caused by obstruction of the lymphatics at the base of the mesentery or in the cisterna chyli and/or thoracic duct. (Protein-losing enteropathy usually accompanies this condition.) The aim of this study was to define the aetiology of chylous ascites and to correlate this with methods and outcome of treatment. The influence of protein-losing enteropathy on prognosis was also investigated.
been excluded from this study because of inadequate documentation. The remaining 45 patients have been reviewed retrospectively. Their median age at presentation was 12 (range 1-80) years: 23 patients were aged < 15 years. The male:female ratio was 1 . 3 : l .
ClinI~~ul pr.ec.enrutioriund iiircstijlutioii Thirty-four patients presented with abdominal distension, 27 with malnutrition and hypoproteinaemia, 21 with dyspnoea and 21 with steatorrhoea (Tub/
