Chylothorax Clinical Presentation

  • Author: Sasha D Adams, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 4, 2012
 

History

  • Usually, the patient remains asymptomatic until a large amount of chyle accumulates in the pleural space.
  • The average latent period between the insult and the onset of symptoms is 7-10 days. Symptoms include the following:
  • Rarely, patients may experience a rapid accumulation of fluid in the pleural space, causing a tension chylothorax. This is of particular concern following a pneumonectomy. These patients experience a rapid hemodynamic and respiratory compromise, similar to classic tension pneumothorax.
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Physical

  • Findings on examination are nonspecific and include the following:
    • Decreased breath sounds
    • Shifting dullness
  • If the patient has an existing chest tube, excess drainage of 400-600 cc per 8-hour period is concerning for a chylous leak, particularly in postsurgical patients.
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Causes

  • Nontraumatic
    • Malignant etiologies account for more than 50% of chylothorax diagnoses and are separated into lymphomatous and nonlymphomatous. Lymphoma is the most common cause, representing about 60% of all cases, with non-Hodgkin lymphoma more likely than Hodgkin lymphoma to cause a chylothorax. By comparison, nonlymphomatous causes are rare.
    • Nonmalignant etiologies are separated into idiopathic, congenital, and miscellaneous.
      • Clinicians must rule out all possible malignant causes before designating the chylothorax as idiopathic.
      • Congenital chylothorax is the leading cause of pleural effusion in neonates.[1]
      • Miscellaneous causes include cirrhosis, tuberculosis, sarcoidosis, amyloidosis, and filariasis.
  • Traumatic
    • Trauma is the second leading cause of chylothorax (25%).
    • Iatrogenic injury to the thoracic duct has been reported with most thoracic procedures. In particular, cardiothoracic surgery has been associated with 69-85% of cases of chylothorax in children.[2] Milonakis et al examined their experience in managing chylothorax following congenital heart surgery. Of 1341 children who underwent correction of congenital heart disease, 18 (1.3%) developed postoperative chylothorax, which was managed with a therapeutic protocol that included complete drainage of chyle collection and controlled nutrition. Six children received adjunctive somatostatin. When lymph leakage persisted (range, 2.5-14.7 mL/kg/d for 8-42 days) despite conservative management, surgical intervention was implemented. Once chylothorax resolved, a 6-week diet of medium-chain triglycerides was given.No deaths occurred. Conservative therapy was effective in 15 patients (83.3%); 3 patients with persistent drainage required thoracotomy with pleurodesis to achieve resolution, 2 of whom had not had an effective response with previously attempted chemical pleurodesis with doxycycline (range of duration leakage, 5.1-7.4 mL/kg/d for 15-47 days).
    • Nonsurgical traumatic injury is a rare cause, usually secondary to penetrating trauma.
  • Pseudochylothorax
    • Chylothorax must be distinguished from pseudochylothorax, or cholesterol pleurisy, which results from accumulation of cholesterol crystals in a chronic existing effusion.
    • The most common cause of pseudochylothorax is chronic rheumatoid pleurisy, followed by tuberculosis and poorly treated empyema.
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Contributor Information and Disclosures
Author

Sasha D Adams, MD  Resident Physician, Department of Surgery, University of Texas at Houston School of Medicine

Sasha D Adams, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, and Association of Women Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

James Cipolla, MD  Attending Surgeon, Department of Traumatology and Critical Care, St Luke's Hospital; Attending Surgeon, Department of Traumatology, Reading Hospital; Assistant Clinical Professor of Surgery, University of Pennsylvania School of Medicine

James Cipolla, MD is a member of the following medical societies: American College of Surgeons and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mounzer Al Al Samman, MD  Department of Internal Medicine, Division of Gastroenterology, Assistant Professor, Texas Tech University School of Medicine

Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

BS Anand, MD  Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Rosemary Kozar, MD, PhD, to the writing and development of this topic.

References

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Anteroposterior upright chest radiograph shows a massive left-sided pleural effusion with contralateral mediastinal shift. Image courtesy of Allen R. Thomas, MD.
A CT scan of the chest of a 3-year old child showing left side effusion and underlying parenchymal infiltrate and atelectasis. Image courtesy of Ibrahim Abdulhamid, MD.
 
 
 
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