|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 309-311
Significance of Octreotide in congenital chylous ascites
MJA Jalal1, BM Pittappilly2
1 Department of Family Medicine, Lakeshore Hospital and Research Centre, Ernakulam, Kerala, India
2 Department of Pediatrics, Lakeshore Hospital and Research Centre, Ernakulam, Kerala, India
|Date of Web Publication||28-Jul-2015|
Dr. MJA Jalal
Department of Family Medicine, Lakeshore Hospital and Research Centre, Nettoor, P.O, Maradu, NH 47 - Bypass, Ernakulam - 682 040, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jalal M, Pittappilly B M. Significance of Octreotide in congenital chylous ascites. Astrocyte 2015;1:309-11
Chylous ascites is defined as the accumulation of chyle in the peritoneal cavity.  It is a difficult disorder due to the serious mechanical, nutritional, and immunological consequences of the constant loss of protein and lymphocytes.  Chylous ascites is not commonly seen in infants. The etiology of most cases of chylous ascites remains unknown. Congenital chylous ascites is primarily related to inadequate lymphatic drainage as a result of mal-development of the intraabdominal lymphatic duct.  Here we describe an 8-month-old infant with congenital chylous ascites who improved with Octreotide therapy.
An 8-month-old baby boy, who was born out of a nonconsanguineous marriage, by full term normal delivery, presented with abdominal distension since birth, which was noticed to be progressively increasing. He had malabsorption and was malnourished with a weight loss of nearly 2 kg. There was no history of any trauma or abdominal surgeries.
On examination, the child was not in any distress except for dyspnea on lying flat. There was no pallor, jaundice, or significant lymphadenopathy. Abdomen was markedly distended (abdominal girth: 55 cm). He had fluid thrill. Abdominal diagnostic tap was done [Table 1] and chylous fluid was aspirated (fluid protein - 3 g/dl, lactate dehydrogenase [LDH] - 460 U/L suggesting an exudate). Ascitic fluid triglycerides was 4352 mg/dl, serum triglycerides was 159 mg/dl, and serum cholesterol was 101 mg/dl. Ultrasound abdomen showed gross ascites. Lymphoscintigraphy [Figure 1] confirmed the abnormalities of the thoracic duct. There was an arrest of progression of lymphatic tracer beyond the lower abdominal area indicative of thoracic duct anomaly.
Lymphoscintigraphy was performed prior to other imaging modalities since it is a noninvasive, superior, and cheaper investigating modality, which clearly demonstrates anatomic defect in the lymphatic pathway and rules out ascites of lymphatic origin.
|Figure 1: Radionuclide Lymphoscintigraphy. Abdominal Lymphoscintigraphy was done by inter digital subcutaneous injection of 99mTc sulfur colloid in the lower limbs. The progression of radio colloid through lymphatic channel was imaged sequentially up to 3 h of study. The progression of radio colloid image was seen with visualization of bilateral inguinal lymph nodes signifying patent lower limb lymphatic drainage. Only right para iliac lymph nodes were visualized in the abdominal imaging. Findings are consistent with lymph node blockade at the lower abdominal level indicative of thoracic duct anomaly/retro peritoneal pathology.|
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His clinical picture and investigations were suggestive of congenital chylous ascites. He was kept on very low fat, high protein, high carbohydrate diet, multivitamins, and cholecalciferol supplements. He improved with diet therapy and medium chain triglycerides (given in the form of coconut oil). Later on, he relapsed with progressive abdominal distension. He was started on Octreotide infusion 1.5 mcg/kg/h. He improved with the somatostatin analog. The option of total parenteral nutrition was not considered due to the socioeconomic reasons of the family. He is on regular follow-up. He did not have any further episodes of relapses and is now growing on the 10th centile.
Morton first described chylous ascites in an infant in 1691.  The incidence of the condition has always been underestimated, and is thought to be between 1 in 50,000 and 1 in 100,000 hospital admissions.  Congenital chylous ascites, due to an inadequate lymphatic drainage from the intestine, resulting from mal-development of the intraabdominal lymphatic system,  is even rarer, but is the most frequent cause of nonimmunologic peritoneal effusion. The pathogenesis is poorly understood and genetic factors are discriminated. Consanguinity is a common feature and males are more liable for the condition.  Cases of chylous ascites involving twins have also been reported.  Paracentesis is the most useful diagnostic step , [Table 2].
A diet with medium-chain triglyceride (coconut oil based) decreases the drainage of chyle into the lymphatics. Orlistat has also been successfully used as an alternative to low fat diet. Lymphatic vessels of the intestine have somatostatin receptors.  Caty et al. reported a successful treatment of congenital chylous ascites by a somatostatin analog.  Multiple case reports describe the use of octreotide, a somatostatin analog, in the management of chylous ascites. A combination of total parenteral nutrition and subcutaneous octreotide has been used to successfully treat congenital chylous ascites in a newborn. 
Experimental work in humans has shown that somatostatin can significantly decrease postprandial increases in triglyceride levels. This effect cannot be explained by either inhibition of gastric emptying or inhibition of exocrine pancreatic secretion. Octreotide is most likely effective in chylous ascites on account of its ability to inhibit lymphatic flow.
| References|| |
Wallis RL, Scholbert HA. Chylous and pseudo-chylous ascites. Q J Med 1909-1910;3:30-9.
Vasko JS, Tapper RI. The surgical significance of chylous ascites. Arch Surg 1967;95:355-68.
Levine C. Primary disorders of the lymphatic vessels - a0 unified concept. J Pediatr Surg 1989;24:233-40.
Flores S, Leungas J, Arredondo-Vega F, Guízar-Vázquez J. Chylous ascites in sibs from a consanguineous marriage. Am J Med Genet 1979;3:145-8.
Evers KG, Huth F. Congenital lymphatic-vessel dysplasia with intestinal lymphangiectasie and chylous ascites in twins. Monatsschr Kinderheilkd 1977;125:526-9.
Leonhardt A, Schmidt W, Wille L. Fetal and neonatal ascites : a0 report of 15 cases and a review of the literature. Klin Padiatr 1987;199:9-14.
Chye JK, Lim CT, Van der Heuvel M. Neonatal chylous ascites - r0 eport of three cases and review of the literature. Pediatr Surg Int 1997;12:296-8.
Chen J, Lin RK, Hassanein T. Use of orlistat (xenical) to treat chylous ascites. J Clin Gastroenterol 2005;39:831-3.
Caty MG, Hilfiker ML, Azizkhan RG, Glick PL. Successful treatment of congenital chylous ascites with a somatostatin analogue. Pediatr Surg Int 1996;11:396-7.
Olivieri C, Nanni L, Masini L, Pintus C. Successful management of congenital chylous ascites with early octreotide and total parenteral nutrition in a newborn. BMJ Case Rep 2012;2012.pii:bcr2012006196.
[Table 1], [Table 2]