Chylothorax

Chylothorax
ICD-10	I89.8, J91
ICD-9	457.8, 511.9
DiseasesDB	29612
eMedicine	med/381
MeSH	D002916

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Overview

Chylothorax, a type of pleural effusion is the accumulation of chyle in the pleural cavity secondary to destruction or obstruction of the thoracic duct or its tributaries. Chylothorax is most commonly right-sided(50%) because of the anatomic location of the thoracic duct, left-sided (33.3%), or bilateral (16.66%). Thoracic duct damage above the fifth thoracic vertebra results in a left-sided chylothorax whereas damage to the thoracic duct below fifth thoracic vertebra leads to a right-sided effusion.

Classification

Chylothorax may be classified as

Chylothorax

Non-traumatic

Traumatic

Malignancy

Diseases

Idopathic

Non- Iatrogenic

Iatrogenic

- Sarcoidosis - Haemangiomatosis - Tuberculosis - Heart failure -Benign tumour - Amyloidosis -Lymphangiolei -omyomatosis - Filariasis - Transdiaphrgmatic movement of chylous ascitic fluid - SVC obstruction

- Knife injury - Childbirth - Forceful cough or emesis - Blunt trauma to the thorax - Bullet wound

- Radiation - Thoracic surgery - Head and neck surgery

Causes

Its cause is usually leakage from the thoracic duct or one of the main lymphatic vessels that drain to it. The most common causes are lymphoma and trauma caused by thoracic surgery. The effusion is characteristically white and milky in appearance and contains high levels of triglycerides.

In animals, chylothorax usually results from diseases that cause obstruction to the thoracic duct preventing lymph from draining normally into the venous system. Examples include tumors, heartworm disease, right sided cardiac failure, or idiopathic lymphangiectasia. The most effective form of treatment is surgical ligation of the thoracic duct combined with partial pericardectomy.

Differentiating chylothorax from other Diseasess

Chylothorax must be differentiated from

• Empyema
• Pseudochylothorax
• Tuberculosis
• Chronic pneumothorax
• Rheumatoid pleurisy
• Chronic hemothorax
• Cirrhosis
• Nephrotic syndrome
• Lymphoma
• Congestive heart failure
• Constrictive pericarditis

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

Please refere to classification for the common risk factors in the development of Chylothorax] are

• Hepatectomy
• Esophagectomy
• Lung surgery
• Cardiac surgery
• Retroperitoneal surgery around the cisterna chyli, example abdominal aortic aneurysm surgery

Natural History, Complications and Prognosis

• If left untreated, 100% of patients with chylothorax may progress to develop
  • Hypovolaemia
  • Malnutrition; as a result of protein, fats and vitamins loss with weight loss and muscle wasting.
  • Hyponatremia and hypocalcemia due to electrolyte loss.
  • Opportunistic infections as a result of immunoglobulins loss.
  • Subtherapeutic effects of medications like digoxin and amiodarone as they are lost through the leaking chyle.
• Common complications of chylothorax include malnutrition, immunosuppression and respiratory distress.
• Prognosis is generally good and the mortality rate from chylothorax has considerably improved from approximately 50% as described in 1948. This is due to the more aggressive management plans implemented. Currently, the worst prognosis is seen in malignant and bilateral chylothoraces.

Diagnosis

Diagnostic Study of Choice

• The diagnosis of chylothorax is with thoracentesis and analysis of the pleural fluid showing a reduced concentration of cholesterol <200mg/dl, and an elevated concentration of triglyceride >110 mg/dl. In centres with available facilities, lipoprotein analysis showing the presence of chylomicrons is the gold standard.

History and Symptoms

• Symptoms of chylothorax depresend on the rate of chyle accumulation and etiology. Symptoms may include the following
• Dyspnea
• Respiratory failure
• Cough
• Swelling in the supraclavicular fossa
• Severe chest pain
• Tachycardia
• Weight loss
• Muscle wasting
• Immunodeficiency
• Malnutrition

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• An elevated concentration of pleural fluid triglyceride >110 mg/dL is diagnostic of chylothorax.

CT scan

Thoracic CT scan may be helpful in the diagnosis of chylothorax. Findings on CT scan suggestive of/diagnostic of chylothorax include

• Pleural effusion

Other Imaging Findings

Other diagnostic studies for chylothorax include

• Lymphangiography with Lipiodol (ethiodized oil) which demonstrates the site of extravasation into the pleural cavity.

Other Diagnostic Studies

• There are no other diagnostic studies associated with chylothorax.

Treatment

Medical Therapy

Chylothorax is a medical emergency and requires prompt treatment. Medical therapy for chylothorax include

• Total parenteral nutrition
• Octreotide injections
• Treatment of the underlying condition
  • Sarcoidosis with steroids
  • Congestive heart failure with diuretics
• Oral low-fat medium-chain triglyceride

Surgery

Surgery is the mainstay of therapy for chylothorax. Surgery is recommended where despite conservative management, patient drains more than 1.5 l/day in an adult or >100 ml/kg body weight per day in a child, leaks chyle at >1 l/day× 5 days or has persistent chyle flow for >2 weeks. It is also recommended if there is a rapid decline in nutritional status despite conservative management.

• Thoracentesis
• Tube thoracostomy
• Thoracoscopy
• Pleurodesis with
  • Talc
  • Tetracycline
  • Bleomycin
  • Povidone
• Pleurectomy
• pleuroperitoneal shunt
• Thoracic duct ligation

Primary Prevention

• There are no established measures for the primary prevention of chylothorax.

Secondary Prevention

• There are no established measures for the secondary prevention of chylothorax.

See also

• Pleural effusion