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. It is an uncommon but established complication of thoracic surgery. 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. Some common symptoms of chylothorax include dyspnea, cough, and severe chest pain. Some physical exams finding include decreased breath sounds and dullness to percussion depending on the size and location of fluid. The definitive 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. Management of chylothorax may be conservative or surgical. Conservative management include total parenteral nutrition, oral low-fat medium-chain triglyceride, and octreotide injections. Surgical management include tube thoracostomy, pleurodesis, pleurectomy, pleuroperitoneal shunt, and thoracic duct ligation.
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
- SVC obstruction
- Thoracic surgery
- Knife injury
- Bullet wound
- Blunt trauma to the thorax
- Head and neck surgery
- Transdiaphrgmatic movement of chylous ascitic fluid
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][8]
- 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][9]
- Hypoalbuminemia
- 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][8]
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.
- lymphoscintigraphy; identify chyle leakage but not the exact site.[8][9][10]
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
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 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. - ↑ 8.0 8.1 8.2 Nicastri DG, Flores RM (2018). "Chylothorax: Abdominal approach". J Thorac Cardiovasc Surg. 155 (2): 814. doi:10.1016/j.jtcvs.2017.09.111. PMID 29106894.
- ↑ 9.0 9.1 Das J, Thambudorai R, Ray S (2015). "Lymphoscintigraphy combined with single-photon emission computed tomography-computed tomography (SPECT-CT): A very effective imaging approach for identification of the site of leak in postoperative chylothorax". Indian J Nucl Med. 30 (2): 177–9. doi:10.4103/0972-3919.152988. PMC 4379685. PMID 25829744.
- ↑ Turpin S, Lambert R (2018). "Lymphoscintigraphy of Chylous Anomalies: Chylothorax, Chyloperitoneum, Chyluria, and Lymphangiomatosis-15-Year Experience in a Pediatric Setting and Review of the Literature". J Nucl Med Technol. 46 (2): 123–128. doi:10.2967/jnmt.117.203281. PMID 29438003.