Chylothorax: Difference between revisions
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==Causes== | ==Causes== | ||
*Common causes of chylothorax include | *Common causes of chylothorax include<ref name="pmid30474568">{{cite journal| author=Yamamoto R, Mokuno Y, Matsubara H, Kaneko H, Sato Y, Iyomasa S| title=Chylothorax after hepatectomy: a case report. | journal=J Med Case Rep | year= 2018 | volume= 12 | issue= 1 | pages= 347 | pmid=30474568 | doi=10.1186/s13256-018-1882-x | pmc=6260677 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30474568 }} </ref><ref name="pmid19766473">{{cite journal| author=McGrath EE, Blades Z, Anderson PB| title=Chylothorax: aetiology, diagnosis and therapeutic options. | journal=Respir Med | year= 2010 | volume= 104 | issue= 1 | pages= 1-8 | pmid=19766473 | doi=10.1016/j.rmed.2009.08.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19766473 }} </ref> | ||
**[[Cancer|Malignacy]] | **[[Cancer|Malignacy]] | ||
**[[Sarcoidosis]] | **[[Sarcoidosis]] | ||
Revision as of 13:53, 30 July 2020
| Chylothorax | |
| ICD-10 | I89.8, J91 |
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| 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.
Historical Perspective
Classification
Chylothorax may be classified as[1][2]
- Non-traumatic
- Malignacy
- Idopathic
- Disease
- Sarcoidosis
- Haemangiomatosis
- Tuberculosis
- Heart failure
- Benign tumor
- Amyloidosis
- Lymphangioleiomyomatosis
- Filariasis
- Transdiaphrgmatic movement of chylous ascitic fluid
- SVC obstruction
- Traumatic
- Iatrogenic
- Non-iatrogenic
- Knife injury
- Childbirth
- Forceful cough or emesis
- Blunt trauma to the thorax
- Bullet wound
| Chylothorax | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non-traumatic | Traumatic | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Malignancy | Diseases | Idopathic | Non- Iatrogenic | Iatrogenic | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| - Sarcoidosis
- Haemangiomatosis - Tuberculosis - Heart failure -Benign tumor - 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pathophysiology
Causes
- Common causes of chylothorax include[1][2]
- Malignacy
- Sarcoidosis
- Tuberculosis
- Heart failure
- Benign tumor
- Transdiaphrgmatic movement of chylous ascitic fluid
- SVC obstruction
- Thoracic surgery
- Head and neck surgery
- Knife injury
- Blunt trauma to the thorax
- Bullet wound
Differentiating chylothorax from other Diseasess
Chylothorax must be differentiated from[2] [3] [4]
- 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 2011, the incidence of pediatric chylothorax was estimated to be 3.7%[5]
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
Common risk factors in the development of Chylothorax] are[1][2][6][7][5]
- Hepatectomy
- Esophagectomy
- Lung surgery
- Cardiac surgery
- Fontan procedure
- Retroperitoneal surgery around the cisterna chyli, example abdominal aortic aneurysm surgery
- Dasatinib therapy
Screening
Natural History, Complications and Prognosis
- If left untreated, 100% of patients with chylothorax may progress to develop[2]
- 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.[2]
- 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.[2]
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.[1][2]
History and Symptoms
- Symptoms of chylothorax depresend on the rate of chyle accumulation and etiology. Symptoms may include the following[1][2]
- 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.[1][2]
- A reduced concentration of cholesterol <200mg/dl is diagnostic of chylothorax.[2]
Electrocardiogram
- There are no ECG findings associated with chylothorax.
X-ray
Ultrasound
CT scan
Thoracic CT scan may be helpful in the diagnosis of chylothorax. Findings on CT scan suggestive of/diagnostic of chylothorax include[1]
MRI
Other Imaging Findings
Other diagnostic studies for chylothorax include
- Lymphangiography with Lipiodol (ethiodized oil) [1] 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[1][2][5]
- Total parenteral nutrition
- Oral low-fat medium-chain triglyceride
- Octreotide injections
- Treatment of the underlying condition
- Sarcoidosis with steroids
- Congestive heart failure with diuretics
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.[1] [2][6][5]
- Thoracentesis
- Tube thoracostomy
- Thoracoscopy
- Pleurodesis with
- Pleurectomy
- pleuroperitoneal shunt
- Thoracic duct ligation
- Lymphatic embolization
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
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 Yamamoto R, Mokuno Y, Matsubara H, Kaneko H, Sato Y, Iyomasa S (2018). "Chylothorax after hepatectomy: a case report". J Med Case Rep. 12 (1): 347. doi:10.1186/s13256-018-1882-x. PMC 6260677. PMID 30474568.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 McGrath EE, Blades Z, Anderson PB (2010). "Chylothorax: aetiology, diagnosis and therapeutic options". Respir Med. 104 (1): 1–8. doi:10.1016/j.rmed.2009.08.010. PMID 19766473.
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ 5.0 5.1 5.2 5.3 Savla JJ, Itkin M, Rossano JW, Dori Y (2017). "Post-Operative Chylothorax in Patients With Congenital Heart Disease". J Am Coll Cardiol. 69 (19): 2410–2422. doi:10.1016/j.jacc.2017.03.021. PMID 28494978.
- ↑ 6.0 6.1 Lo Rito M, Al-Radi OO, Saedi A, Kotani Y, Ben Sivarajan V, Russell JL; et al. (2018). "Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion". J Thorac Cardiovasc Surg. 155 (5): 2069–2077. doi:10.1016/j.jtcvs.2017.11.046. PMID 29249497.
- ↑ Sasaki H, Kimizuka Y, Ogata H, Okada Y, Ota S, Sano T; et al. (2019). "Successful Control of Dasatinib-related Chylothorax by the Japanese Herbal Medicine "Goreisan"". Intern Med. 58 (21): 3139–3141. doi:10.2169/internalmedicine.3002-19. PMC 6875454 Check
|pmc=value (help). PMID 31292394.