Chylothorax

8/08/01 (Druva)

RE: A49 year old male with 2-3 month history of nausea and vomiting, who presented with sharp epigastric abdominal pain.

Question: What are causes and diagnostic aspects of chylothorax?

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Unique Identifier: 21024311 / PubMed Identifier: 11149591

Authors: Markham KM. Glover JL. Welsh RJ. Lucas RJ. Bendick PJ.

Institution: Department of Surgery, Williaim Beaumont Hospital, Royal Oak, Michigan 48703, USA.

Abstract: Anecdotal reports support the use of octreotide in the treatment of traumatic thoracic duct injuries and chylothorax, but no prospective studies have proved its efficacy. We evaluated the effects of octreotide in treating thoracic duct transection in a canine model. Eight mongrel dogs (27.8+/-5.1 kg) were fed one pint of 10.5 per cent milkfat 2 hours before operation. Through a left supraclavicular neck incision, the thoracic duct was identified and transected, producing free flow of chyle. A quarter-inch drain was tunneled subcutaneously from the wound and attached to closed suction. After wound closure dogs were randomized to a control group (n = 4) receiving sham injections of saline subcutaneously three times per day, or a treatment group (n = 4) given 3 microg/kg octreotide three times per day. Postoperatively all dogs were fed a standard low-fat (5-7%) crude fat diet. Drain output was measured each day, and on odd-numbered postoperative days the drainage was analyzed for cholesterol, triglycerides, albumin, and total protein. Fistula closure was defined as drainage <10 ml/24-hour period. Treated dogs achieved fistula closure significantly faster than controls: 3.5+/-1.3 days versus 7.8+/-1.0 days (P = 0.0037). Whereas equivalent amounts of drainage occurred on the day of surgery and on postoperative day one in both groups, by postoperative day 2 the treatment group had significantly less drainage over 24 hours: 63+/-69 ml versus 195+/-79 ml (P = 0.046); this significant difference persisted through postoperative day 5 when drainage began to decrease in the control group. No significant differences between groups were seen in levels of cholesterol, triglycerides, albumin, or protein in the drainage at any time point. We conclude that octreotide is effective in treating thoracic duct injury, leading to an early decrease in drainage and early fistula closure. The mechanism for this effect remains to be clarified.

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Unique Identifier: 20367762 / PubMed Identifier: 10912634

Authors: Romero S.

Institution: Hospital General Universitario de Alicante, Spain. romero_san@gva.es

Abstract: Nontraumatic chylothorax is an uncommon condition of thoracic or abdominal origin caused by multiple disorders, of which malignancy is by far the most frequent one. Because gross appearance of pleural fluid is frequently misleading, pleural fluid and serum lipid analysis is required for its diagnosis. In addition to the presence of chylomicrons, chylothoraces are usually characterized by all three of the following: (1) a triglyceride level of more than 110 mg/dL; (2) a ratio of pleural fluid to the serum triglyceride level of more than 1.0; and (3) a ratio of the pleural fluid to serum cholesterol level of less than 1.0. In patients with lymphoma-related chylothorax refractory to chemotherapy and radiation therapy, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrences. Pleuroperitoneal shunting is considered a safe and effective treatment in the management of persistent chylothorax in children in the absence of chylous ascites. [References: 49]

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Unique Identifier: 99383729 / PubMed Identifier: 10456729

Authors: Perez J. Casal J. Rodriguez W.

Institution: Pulmonary Medicine Section, Veterans Administration Medical Center, San Juan, Puerto Rico 00921-3201, USA.

Abstract: Chylothorax is a rare cause of pleural effusion in association with cardiovascular surgery. A 68-year-old man had a coronary artery bypass graft; 10 days after surgery, he had progressive shortness of breath and a massive left pleural effusion. After chylothorax was diagnosed, it was successfully treated with a thoracostomy tube and total parenteral nutrition. The patient had an uneventful recovery. Nutrition is the most important issue in the treatment of chylothorax. Once chylothorax is identified, nutritional support is the priority, since it will have an important role in the recovery of the patient. Besides our case, we hereby present a short review of the literature regarding the diagnosis and management of this rare entity. [References: 31]

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[Link Directly to Fulltext Article in OVID]

Unique Identifier: 99280917 / PubMed Identifier: 10352651

Authors: Garcia-Zamalloa A. Ruiz-Irastorza G. Aguayo FJ. Gurrutxaga N.

Institution: Service of Internal Medicine, Hospital De Mendaro, Gipuzkoa, Basque Country, Spain. hmzama@hmen.osakidetza.net

Abstract: We report 2 cases of pseudochylothorax and review 172 published cases. Tuberculosis is by far the most frequent cause of pseudochylothorax, accounting for 54% of all caes, with a remarkable association with previous collapse therapy and long-term effusions. The remaining etiologies, including rheumatoid arthritis, are infrequent. Tuberculous pseudochylothorax is usually sterile. Successful treatment of an acute tuberculous pleurisy does not preclude the development of long-term complications such as pseudochylothorax. We do not recommend pleural biopsy initially because of its low yield for etiologic diagnosis. Currently, adenosine deaminase (ADA) values in pleural fluid are not useful to sustain diagnosis or therapeutic decisions. We advise draining only symptomatic cases and treating patients with positive Ziehl-Neelsen stain or Lowenstein culture, and those with growing effusions of suspected tuberculous origin, with antituberculous chemotherapy. Pulmonary decortication should be the last therapeutic step for recurrent and symptomatic cases. [References: 34]

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Unique Identifier: 97306194 / PubMed Identifier: 9163662

Authors: Hillerdal G.

Abstract: Chylothorax is the occurrence of chylus (lymph) in the pleura due to damage to the thoracic duct. There is a high content of triglycerides, and chylomicrons can be seen. It is usually right-sided, since most of the duct is within the right hemithorax. With damage at the level of the aorta, the chyle will appear on the left. Traumatic rupture occurs after accidents or surgery. Of nontraumatic causes, the most common is a malignant lymphoma. Computed tomography (CT) scan of the thorax and upper abdomen should be performed. Lymphography can show where the leakage or blockage is situated. With repeated drains, large amounts of fat, proteins, and lymphocytes are lost. Treatment is with low-fat diet or parenteral nutrition to decrease the amount of chyle, but chemical pleurodesis or ligation of the thoracic duct, usually via thoracoscopy, is often necessary. Pseudochylothorax (cholesterol pleurisy) occurs with long-standing fluid in a fibrotic pleura. The fluid has a high content of cholesterol but no triglycerides or chylomicrons. In both conditions, the pleural fluid is thick, opalescent, whitish or the colour of cafe-au-lait. [References: 47]

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Unique Identifier: 96232789 / PubMed Identifier: 8646499

Authors: Miller JI Jr.

Institution: Division of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.

Abstract: Chylothorax is the presence of lymphatic fluid in the pleural space resulting from a leak of the thoracic duct or one of its major divisions. This condition is being recognized more frequently after both cardiac and general thoracic surgical procedures. Increased understanding of the physiology, pathogenesis, diagnosis, and management of chylothorax has significantly decreased the initial mortality in the majority of medical centers. [References: 8]

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Unique Identifier: 96016603 / PubMed Identifier: 7589411

Authors: Villena V. de Pablo A. Martin-Escribano P.

Institution: Servicio de Neumologia, Hospital Universitario 12 de Octubre, Madrid, Spain.

Abstract: Chylous ascites and chylothorax have rarely been reported as a consequence of severe right heart failure. To our knowledge, this is the first case report of both disorders occurring as a result of ischaemic cardiomyopathy. The autopsy findings and possible mechanisms of production are discussed.

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Unique Identifier: 95041284 / PubMed Identifier: 7953487

Authors: Johnstone DW. Feins RH.

Institution: Division of Thoracic Surgery, University of Rochester Medical Center, New York.

Abstract: The management of chylothorax requires a thorough understanding of the anatomy and pathophysiology of the major thoracic lymphatics, prompt diagnosis, and (with rare exception) conservative management, including evacuation of the pleural space, nutritional support, and measures to reduce chyle production. A minority of chylothoraces will fail to resolve with these measures. Surgical intervention is then required to prevent chronic metabolic deterioration and death. [References: 84]

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Unique Identifier: 95005730 / PubMed Identifier: 7921507

Authors: Paes ML. Powell H.

Institution: Department of Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle upon Tyne.

Abstract: Chylothorax is occasionally found in malignant disease and following sympathectomy, but is seen more frequently after cardiothoracic surgery. The varied anatomy of the thoracic duct, limited individual experience and a lack of appreciation of the factors indicating surgical intervention have led to controversy regarding its optimal management. This article reviews historical aspects, clinical features and guidelines for conservative and surgical management. [References: 66]

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Unique Identifier: 92354430 / PubMed Identifier: 1643953

Authors: Valentine VG. Raffin TA.

Institution: Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Calif.

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Unique Identifier: 90132210 / PubMed Identifier: 2693564

Authors: Ossorio MA. Roy TM. Fields CL.

Abstract: The incidence of nontraumatic chylothorax is sufficiently low that most primary care physicians are unclear about the criteria for this diagnosis and the proper treatment options. A ten-year review of patients with pleural effusion treated by the university medical service identified 12 individuals with chylothorax. These patients and a current review of the English language medical literature provide us an opportunity to review the clinical presentation of chylothorax. The differential diagnosis and treatment options are reviewed. [References: 15]