Chylothorax: Difference between revisions
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*Lymphatic fluid in pleural space | *Lymphatic fluid in pleural space | ||
*Due to disruption or obstruction of the thoracic duct | *Due to disruption or obstruction of the thoracic duct | ||
*Differentiate from pseudocylothorax, a chronic cholesterol containing, chyliform pleural effusion not from thoracic duct disruption<ref>Light RW | |||
. Chylothorax and pseudochylothorax. In: Pleural Diseases, 6th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins; 2013.</ref> | |||
*Causes: | *Causes: | ||
**Malignancy (50%), especially [[lymphoma]] | **Malignancy (50%), especially [[lymphoma]] | ||
| Line 9: | Line 11: | ||
**[[Sarcoidosis]] | **[[Sarcoidosis]] | ||
**[[Amyloidosis]] | **[[Amyloidosis]] | ||
**[[ | **[[Lymphatic filariasis]] | ||
**Idiopathic | **Idiopathic | ||
==Clinical Features== | ==Clinical Features== | ||
*[[Dyspnea]], tachypnea, [[hypoxia]] | |||
*Decreased breath sounds | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{SOB DDX}} | |||
==Evaluation== | ==Evaluation== | ||
*Thoracentesis with fluid: | *[[CXR]] | ||
**Triglycerides | *[[ECG]] | ||
**Cholesterol | *CBC, BMP | ||
**LDH | *+/- BNP, [[D-dimer]], [[Troponin]] to rule out other etiology | ||
**Protein | *+/- Bedside [[lung ultrasound]] | ||
**Culture and gram stain | *[[Thoracentesis]] with classically white, odorless, milky fluid: | ||
**Cell differential and count | **Differentiate from empyema and pseudochylothorax | ||
*Serum LDH and total protein comparison | **In congenital chylothorax, pleural fluid is serous and becomes chylous when milk feedings start | ||
**Pleural fluid analysis<ref>Tutor JD. Chylothorax in Infants and Children. Pediatrics. April 2014, VOLUME 133 / ISSUE 4.</ref>: | |||
***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<ref>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.</ref> | |||
==Management== | ==Management== | ||
*Thoracic duct leaks close spontaneously in ~50% of patients<ref>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]</ref> | |||
*Treat underlying cause (e.g. chemoradiation for malignancy) | |||
*Refractory: pleurodesis, thoracic duct ligation, pleuroperitoneal shunt, pleurectomy | |||
==Disposition== | ==Disposition== | ||
| Line 35: | Line 51: | ||
==See Also== | ==See Also== | ||
*[[Pleural effusion]], [[empyema]] | |||
*[[Thoracentesis]] | |||
==External Links== | ==External Links== | ||
Latest revision as of 23:32, 26 February 2017
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:
- Malignancy (50%), especially lymphoma
- Trauma (including iatrogenic)
- Cirrhosis
- Tuberculosis
- Sarcoidosis
- Amyloidosis
- Lymphatic filariasis
- Idiopathic
Clinical Features
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
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
- ↑ Light RW . Chylothorax and pseudochylothorax. In: Pleural Diseases, 6th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins; 2013.
- ↑ Tutor JD. Chylothorax in Infants and Children. Pediatrics. April 2014, VOLUME 133 / ISSUE 4.
- ↑ 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.
- ↑ 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]