Lymphatic Leakage Workup

Updated: Apr 24, 2017
  • Author: Michael Omidi, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Workup

Laboratory Studies

The diagnosis of lymphatic fistula, chylous ascites, or chylothorax is largely clinical. To confirm the diagnosis, ascitic or pleural fluid is assayed. The presence of chylomicrons and a triglyceride level higher than 110 mg/dL confirm the diagnosis of a chylous leak. [24]

The presence of chyle may be confirmed in the laboratory by measuring fat and protein content, pH, and specific gravity. Chyle has a fat content of 0.4-4.0 g/dL, a protein content of approximately 3 g/dL, a pH of greater than 7.5, and a specific gravity of greater than 1.010 g/dL.

It is important to note that a clinical diagnosis of chylothorax supersedes biochemical analysis of chest tube output and may result in false-negative results. [24]

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Imaging Studies

Chest radiography, abdominal ultrasonography, or computed tomography (CT) of the abdomen or chest can confirm the presence of a fluid collection, which can later be drained and sent off to the laboratory. Lymphoscintigraphy [25] and magnetic resonance (MR) lymphography are noninvasive diagnostic procedures that can identify leakage of chyle by using contrast specific to the modality of imaging.

Lymphangiography is a diagnostic procedure that has regained popularity in the past decade. [9, 15, 2, 3, 26, 27] Two techniques have been described for diagnostic lymphangiography, as follows:

  • Bipedal lymphangiography - This technique, the traditional approach, requires cutdown to the lymphatic channels and dissection and cannulation of the pedal lymphatics between the first and second web spaces [28, 29, 30]
  • Intranodal lymphangiography - This technique does not require dissection and cannulation of lymphatics and has been used successfully in the pediatric population [30]

Lymphangiography also has therapeutic uses (see Interventional Therapy), whereas MR lymphography and lymphoscintigraphy do not. The oily contrast agent used in lymphangiography, ethiodized oil, evokes an inflammatory and granulomatous reaction during its extravasation, leading to cessation of lymphatic leakage. [15, 14]

Fistulography and white blood cell scanning are other diagnostic tools that may be used to help diagnose lymphatic fistulas; however, they are rarely used today.

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Diagnostic Procedures

Traditional, ultrasonographic, or CT-directed paracentesis may be performed to confirm the presence of chylous ascites. Chylothorax may be demonstrated by means of diagnostic or therapeutic thoracocentesis. Tube thoracostomy may be used for diagnosis and conservative treatment of chylothorax.

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