eMedicine Specialties > Gastroenterology > Systemic Disease

Chylothorax: Differential Diagnoses & Workup

Author: Rosemary Kozar, MD, PhD, Assistant Professor, Department of Surgery, Division of General Surgery, University of Texas at Houston School of Medicine
Coauthor(s): Sasha D Adams, MD, Resident Physician, Department of Surgery, University of Texas at Houston School of Medicine; James Cipolla, MD, Attending Surgeon, St Luke's Hospital
Contributor Information and Disclosures

Updated: Aug 24, 2009

Differential Diagnoses

Empyema, Pleuropulmonary
Hemothorax

Other Problems to Be Considered

AIDS-related complex
Congestive heart failure
Exudative pleural effusion
Malignant pleural effusion
Pseudochylothorax

Workup

Laboratory Studies

  • The following laboratory studies are not required for diagnosis but are useful to determine the metabolic and nutritional status of the patient:
    • Serum electrolyte tests
    • Serum albumin test
    • CBC count with differential to look for lymphocyte depletion

Imaging Studies

  • Chest radiographic findings are nonspecific for chylothorax and indistinguishable from other causes of pleural effusion.
    • Determine if effusion is bilateral.
    • Look for a mediastinal shift.
  • If the etiology of the chylothorax is unknown, obtain CT scans of the chest and abdomen to rule out malignancy.
  • Lymphangiography is useful when the anatomy of the thoracic duct needs to be defined preoperatively or when the site of the leak is not clinically obvious.

Procedures

  • Thoracentesis and pleural fluid analysis are the criterion standards to establish a diagnosis of chylothorax. Alternatively, in a postsurgical patient, tube thoracostomy output can be analyzed.
  • Pleural fluid analysis for triglyceride content helps to confirm a diagnosis of chylothorax.
    • A level greater than 110 mg/dL reflects a 99% chance that the fluid is chyle.
    • A level less than 50 mg/dL reflects only a 5% chance that the fluid is chyle.
    • If the level is 50-110 mg/dL, use lipoprotein analysis to inspect the pleural fluid for chylomicrons or cholesterol crystals.
    • A ratio of pleural fluid cholesterol to triglyceride of less than 1 is also diagnostic.
  • A fasting patient may have serous-appearing pleural fluid. To confirm the diagnosis, administer cream through a nasoenteric tube prior to fluid collection. The cream will change the chylous production from serous to the characteristic milky white fluid. This change is diagnostic for a chyle leak.
  • Chylothorax can be distinguished from pseudochylothorax by fluid analysis. In pseudochylothorax, the cholesterol level is greater than 200 mg/dL, no chylomicrons are present, and cholesterol crystals are seen at microscopy.

More on Chylothorax

Overview: Chylothorax
Differential Diagnoses & Workup: Chylothorax
Treatment & Medication: Chylothorax
Follow-up: Chylothorax
Multimedia: Chylothorax
References
Further Reading
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References

  1. Ergaz Z, Bar-Oz B, Yatsiv I, Arad I. Congenital chylothorax: clinical course and prognostic significance. Pediatr Pulmonol. Aug 2009;44(8):806-11. [Medline].

  2. Milonakis M, Chatzis AC, Giannopoulos NM, Contrafouris C, Bobos D, Kirvassilis GV, et al. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg. Jul-Aug 2009;24(4):369-73. [Medline].

  3. Paul S, Altorki NK, Port JL, Stiles BM, Lee PC. Surgical management of chylothorax. Thorac Cardiovasc Surg. Jun 2009;57(4):226-8. [Medline].

  4. Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health. Dec 2008;44(12):716-21. [Medline].

  5. Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg. Jul 2009;88(1):246-51; discussion 251-2. [Medline].

  6. Ammori JB, Pickens A, Chang AC. Tension chylothorax. Ann Thorac Surg. Aug 2006;82(2):729-30.

  7. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg. Dec 1997;84(12):1711-6. [Medline].

  8. Clarke SA, Lakhoo K, Sherwood W. Somatostatin for intractable postoperative chylothorax in a premature infant. Pediatr Surg Int. May 2005;21(5):390-1. [Medline].

  9. Hillerdal G. Chylothorax and pseudochylothorax. Eur Respir J. May 1997;10(5):1157-62. [Medline].

  10. Maskell NA, Butland RJ. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. May 2003;58 Suppl 2:ii8-17.

  11. Merrigan BA, Winter DC, O'Sullivan GC. Chylothorax. Br J Surg. Jan 1997;84(1):15-20. [Medline].

  12. Mohseni-Bod H, Macrae D, Slavik Z. Somatostatin analog (octreotide) in management of neonatal postoperative chylothorax: is it safe?. Pediatr Crit Care Med. Jul 2004;5(4):356-7. [Medline].

  13. Ogi S, Fukumitsu N, Uchiyama M. A case of chylothorax diagnosed by lymphoscintigraphy using Tc-99m HSA-DTPA. Clin Nucl Med. Jun 2002;27(6):455-6. [Medline].

  14. Paes ML, Powell H. Chylothorax: an update. Br J Hosp Med. May 4-17 1994;51(9):482-90. [Medline].

  15. Postma GN, Keyser JS. Management of persistent chylothorax. Otolaryngol Head Neck Surg. Feb 1997;116(2):268-70. [Medline].

  16. Rice TW, Milstone AP. Chylothorax as a result of chronic lymphocytic leukemia: case report and review of the literature. South Med J. Mar 2004;97(3):291-4. [Medline].

  17. Sieczka EM, Harvey JC. Early thoracic duct ligation for postoperative chylothorax. J Surg Oncol. Jan 1996;61(1):56-60. [Medline].

  18. Valentine VG, Raffin TA. The management of chylothorax. Chest. Aug 1992;102(2):586-91. [Medline].

  19. Vallieres E, Shamji FM, Todd TR. Postpneumonectomy chylothorax. Ann Thorac Surg. Apr 1993;55(4):1006-8. [Medline].

  20. Wemyss-Holden SA, Launois B, Maddern GJ. Management of thoracic duct injuries after oesophagectomy. Br J Surg. Nov 2001;88(11):1442-8. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

chylothorax, pleural effusion, pediatric chylothorax, neonatal chylothorax, thoracic duct leak, thoracic duct ligation, pleural chyle, pleural space, lymphoma, pleuroperitoneal shunt, pleurodesis, pleurectomy, chyle, postesophagectomy chylothorax, thoracentesis, lymphatic fluid, thoracic duct injury, loculated chylothorax

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Contributor Information and Disclosures

Author

Rosemary Kozar, MD, PhD, Assistant Professor, Department of Surgery, Division of General Surgery, University of Texas at Houston School of Medicine
Rosemary Kozar, MD, PhD is a member of the following medical societies: Society of University Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

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.

James Cipolla, MD, Attending Surgeon, St Luke's Hospital
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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, 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; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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