Case Presentation: A 53 year old male with history of decompensated non-alcoholic steatohepatitis cirrhosis (with ascites and esophageal varices), chronic kidney disease stage 3, type 2 diabetes mellitus, colon adenocarcinoma (TNM stage: T3N1) s/p FOLFOX (folinic acid, fluorouracil, and oxaliplatin) and right hemicolectomy 3 years ago was admitted from the liver clinic for acute kidney injury (AKI). A day prior to admission, a large volume paracentesis (LVP) with 12 liters of ascitic fluid removal and subsequent albumin replacement had been performed. His home medications included ciprofloxacin, rifaximin, midodrine, lactulose and ranitidine. Diuretics were stopped during previous hospitalization due to recurrent AKIs. In a recent admission, two weeks prior, his AKI had been responsive to albumin, octreotide and midodrine. Of note, transjugular intrahepatic portosystemic shunt (TIPS) had been placed three months previously due to refractory ascites. Ascites failed to improve despite TIPS; rather, ascitic fluid became more opaque. Moreover, his requirement of weekly LVP persisted. On arrival, his vitals remained stable (temperature 36.6 °C, blood pressure 106/62 mmHg, and pulse 74 beats per minute). Physical examination was significant for abdominal distension and mild scleral icterus. Labs were significant for creatinine 2.49 mg/dL (baseline 1.2 mg/dL), hemoglobin 9 gm/dL (baseline 9 mg/dL), INR 1.2, albumin 3 gm/dL and total bilirubin 1.9 mg/dL. Paracentesis did not reveal spontaneous bacterial peritonitis. Remarkably, ascitic fluid triglyceride level was 1799 U, indicating presence of chylous ascites (CA). Liver and abdominal ultrasound revealed patent TIPS. Velocities at TIPS were all within expected range: 99 cm/sec at proximal, 113 cm/sec at mid and 97 cm/sec at distal regions. Due to AKI, diuretics were avoided. Patient was treated with albumin, midodrine, and octreotide with the concern for hepatorenal syndrome, which resulted in mild serum creatinine improvement from 2.5 mg/dL to 1.8 mg/dL. Following three days of treatment resulting in stabilized creatinine around 1.8, patient was discharged on all of his home medications in addition to subcutaneous octreotide.
Discussion: TIPS is often a treatment option for refractory ascites (lack of improvement despite high dose diuretics while on sodium restricted diet or frequent ascites recurrence shortly following therapeutic paracentesis). Its complications include worsening hepatic encephalopathy, liver failure, and TIPS failure with recurrent ascites. Lack of ascites improvement following TIPS is rare but may result from TIPS obstruction or thrombosis. While CA can develop in liver cirrhosis due to trauma, obstruction of lymphatic system, or malignancy, post-TIPS chylous ascites has not been described previously in literature. CA in liver cirrhosis can be a poor prognostic marker with increased incidence of sepsis and possible underlying malignancy. In this first documented case of post-TIPS CA, as TIPS was functional and patent, revision was inappropriate. Liver transplant was postponed given history of colon cancer within last 3 years. Thus, overall plan is to continue LVP presently, with liver transplant once colon cancer remission is achieved for at least 5 years.
Conclusions: Chylous ascites in liver cirrhosis is rare, and post-TIPS CA has not been reported in literature. Clinicians must attempt to identify and manage underlying causes of CA as it generally yields poor prognosis.