Chylothorax Workup

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

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
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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.
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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.
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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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