Chylothorax

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

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor: Joanna Ekabua, M.D. [2]

Synonyms and Keywords: Chylothorax

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. Depending on the etiology, chylothorax could be exudative ( tuberculosis) or transudative (svc obstruction). 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

  • Chylothorax was first described in 1633 by Bartolet, and Quincke reported the first case in 1875. [1]
  • In 1917, Brandt was the first to discover the association between tuberculosis and the development of chylothorax. [1]

Classification

Chylothorax may be classified as[2][3]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

Differentiating chylothorax from other Diseasess

Chylothorax must be differentiated from[3] [8] [9][4]

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%[10] [11]
  • Incidence post cardiothoracic surgeries are between 0.9% and 6.6%.
  • Incidence post esophageal surgeries range from 0.2% to 10%.

Age

  • Patients of all age groups may develop chylothorax.[11][10]

Gender

  • Chylothorax affects men and women equally.

Race

  • There is no racial predilection for chylothorax.

Risk Factors

Common risk factors in the development of Chylothorax] are[2][3][12][13][10][14][15][16][17][5][18][19]

Screening

  • There is insufficient evidence to recommend routine screening for chylothorax.

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

  • There are no ECG findings associated with chylothorax.

X-ray

X-ray showing bilateral chylothorax post mastectomy (Image B). Normal preop Xray (image A) showing costophrenic angle (yellow arrowhead), Image C shows post chylothorax management and restoration of the costophrenic angle (yellow arrow) (Picture courtesy: National Library of Medicine)


Ultrasound

Transthoracic ultrasound may be helpful in the diagnosis of chylothorax. Finding loculated fluid collection is suggestive of chylothorax. [11]

CT scan

Thoracic CT scan may be helpful in the diagnosis of chylothorax.CT scan is valuable in the location and treatment decision of chylothorax Findings on CT scan suggestive of chylothorax include[2] pleural effusion

Non-contrast CT showing chyle collection. (Picture courtesy: National Library of Medicine)


MRI

  • There are no MRI findings associated with chylothorax.

Other Imaging Findings

Other diagnostic studies for chylothorax include

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[2][3][10] Conservative therapy aims at minimizing lymph flow through the damaged thoracic duct.[20][11][6][4]

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.[2] [3][4][12][10][20][15][6][18][22]

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. 1.0 1.1 1.2 1.3 1.4 1.5 Kant S, Verma SK, Anand SC, Prasad R, Verma RK (2011). "Development of bilateral chylothorax in a younger female secondary to tuberculosis". Lung India. 28 (1): 56–9. doi:10.4103/0970-2113.76303. PMC 3099513. PMID 21654988.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 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.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 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.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Vaz MA, Fernandes PP (2006). "[Chylothorax]". J Bras Pneumol. 32 Suppl 4: S197–203. doi:10.1590/s1806-37132006000900006. PMID 17273624.
  5. 5.0 5.1 5.2 5.3 Rajagopala S, Kancherla R, Ramanathan RP (2018). "Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature". Respiration. 95 (4): 260–268. doi:10.1159/000484694. PMID 29316546.
  6. 6.0 6.1 6.2 Waterfield T, Lakhoo K (2010). "Challenges in the management of refractory bilateral idiopathic congenital chylothoraces in a newborn". Eur J Pediatr Surg. 20 (3): 198–201. doi:10.1055/s-0029-1241874. PMID 19882503.
  7. Austin A, Al-Faris F, Modi A, Chopra A (2019). "A transudative chylothorax associated with superior vena cava syndrome". Respir Med Case Rep. 28: 100898. doi:10.1016/j.rmcr.2019.100898. PMC 6626116 Check |pmc= value (help). PMID 31338288.
  8. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  9. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  10. 10.0 10.1 10.2 10.3 10.4 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.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Muniz G, Hidalgo-Campos J, Valdivia-Tapia MDC, Shaikh N, Carreazo NY (2018). "Successful Management of Chylothorax With Etilefrine: Case Report in 2 Pediatric Patients". Pediatrics. 141 (5). doi:10.1542/peds.2016-3309. PMID 29703801.
  12. 12.0 12.1 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.
  13. 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.
  14. 14.0 14.1 14.2 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.
  15. 15.0 15.1 Townshend AP, Speake W, Brooks A (2007). "Chylothorax". Emerg Med J. 24 (2): e11. doi:10.1136/emj.2006.042028. PMC 2658219. PMID 17251600.
  16. 16.0 16.1 16.2 16.3 16.4 Benninger LA, Ross JA, Leon ME, Reddy R (2018). "An unusual case of chylothorax". Respir Med Case Rep. 25: 318–322. doi:10.1016/j.rmcr.2018.10.020. PMC 6205929. PMID 30402386.
  17. Pospiskova J, Smolej L, Belada D, Simkovic M, Motyckova M, Sykorova A; et al. (2019). "Experiences in the treatment of refractory chylothorax associated with lymphoproliferative disorders". Orphanet J Rare Dis. 14 (1): 9. doi:10.1186/s13023-018-0991-3. PMC 6327395. PMID 30626415.
  18. 18.0 18.1 Jacob S, Meneses A, Landolfo K, El-Sayed Ahmed M, Makey IA, Pham SM; et al. (2019). "Incidence, Management, and Outcomes of Chylothorax after Lung Transplantation: A Single-center Experience". Cureus. 11 (7): e5190. doi:10.7759/cureus.5190. PMC 6649881 Check |pmc= value (help). PMID 31341753.
  19. 19.0 19.1 19.2 Nagano N, Suzuki M, Tamura K, Kobayashi S, Kojima Y, Naka G; et al. (2019). "Refractory Chylothorax and Lymphedema Caused by Advanced Gastric Cancer". Intern Med. 58 (21): 3143–3148. doi:10.2169/internalmedicine.2351-18. PMC 6875443 Check |pmc= value (help). PMID 31292374.
  20. 20.0 20.1 20.2 20.3 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.
  21. 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.
  22. Diaz-Gutierrez I, Rao MV, Andrade RS (2018). "Laparoscopic ligation of cisterna chyli for refractory chylothorax: A case series and review of the literature". J Thorac Cardiovasc Surg. 155 (2): 815–819. doi:10.1016/j.jtcvs.2017.08.140. PMID 29129424.

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