Chylothorax

Background

  • Lymphatic fluid in pleural space
  • Due to disruption or obstruction of the thoracic duct
  • Differentiate from pseudocylothorax, a chronic cholesterol containing, chyliform pleural effusion not from thoracic duct disruption[1]
  • Causes:

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Pediatric-specific

Non-Emergent

Evaluation

  • CXR
  • ECG
  • CBC, BMP
  • +/- BNP, D-dimer, Troponin to rule out other etiology
  • +/- Bedside lung ultrasound
  • Thoracentesis with classically white, odorless, milky fluid:
    • Differentiate from empyema and pseudochylothorax
    • In congenital chylothorax, pleural fluid is serous and becomes chylous when milk feedings start
    • Pleural fluid analysis[2]:
      • Triglycerides > 110 mg/dL
      • Cholesterol
      • LDH
      • Chylomicron analysis
      • Protein
      • Culture and gram stain
      • Cell differential and count
  • Serum LDH, total cholesterol, and total protein comparison
    • Ratio of pleural fluid : serum cholesterol < 1.0 in chylothorax
    • In pseudochylothorax, this ratio will exceed 1.0[3]

Management

  • Thoracic duct leaks close spontaneously in ~50% of patients[4]
  • Treat underlying cause (e.g. chemoradiation for malignancy)
  • Refractory: pleurodesis, thoracic duct ligation, pleuroperitoneal shunt, pleurectomy

Disposition

See Also

External Links

References

  1. Light RW . Chylothorax and pseudochylothorax. In: Pleural Diseases, 6th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins; 2013.
  2. Tutor JD. Chylothorax in Infants and Children. Pediatrics. April 2014, VOLUME 133 / ISSUE 4.
  3. Romero S, Martín C, Hernandez L, et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest. 1998;114(1):154–159.
  4. Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg. 2016 Jan. 49 (1):18-24. [Medline]