Chylous pleural effusion (chylothorax)

Chylothorax refers to the accumulation of chyle containing lymphatic fluid in the pleural space.

A type of pleural effusion.

Results from lymphatic fluid, ref2242ed to as chyle, accumulating in the pleural cavity.

Usually caused by leakage from the thoracic duct or one of the main lymphatic vessels that drain to it.

Most common causes are lymphoma and trauma caused by thoracic surgery.

The effusion is identified by its white and milky appearance.

Fluid contains high levels of triglycerides.

The chyle composition of triglycerides is mostly in the form of chylomicrons.

Usually results from diseases that obstruct the thoracic duct, preventing lymph from draining normally into the venous system.

Associated conditions include: malignancies, right-sided cardiac failure, or idiopathic lymphangiectasia.

Treatment includes draining of the fluid out of the pleural space to prevent inhibition of lung function by the pressure of the chyle.

Pneumoperitoneal shunting is another alternative, preventing loss of essential triglycerides that escape the thoracic duct.

Caused by disruption of the thoracic duct or abnormal lymphatic fluid flow in the thorax.

Classical description of the fluid is milky white or opalescent but half of the patients with chylous effusions this color is lacking.

Causes include: malignancies, trauma, congestive heart failure, sarcoidosis, tuberculosis, radiation to the mediastinum, histoplasmosis, filariasis, and idiopathic.

Malignancies account for half the cases.

Three fourths of the malignant cases are due to lymphoma and lung cancer is the next most common cause of chylothorax.

Trauma, including surgical procedures, accounts for about 25% of the cases.

Because of the proximity of the thoracic duct to the esophagus, aorta, and spine this complication has been reported after nearly all thoracic surgical procedures.

Overall incidence of postoperative chylothorax for thoracic and cardiovascular surgery is approximately 0.5%.

Esophagectomy is consistently associated with a higher incidence of chylothorax than other surgical procedures.

Because fasting is associated with clear chyle it is difficult to recognize intraoperative injuries of the thoracic duct.

In patients with lymphoma usually occurs in advanced disease.

Obstruction of the subclavian vein or superior vena cava from venous access lines can cause chylothorax.

Can be associated with penetrating injuries of the chest, severe emesis, cough, hyperextension of the spine and childbirth.

Most common cause of pleural effusion in the first few days of life.

Managing the process, includes omitting fat from the diet.

Chylothorax is usually managed conservatively by adjusting the diet to eliminate long-chain fatty acids and supplementing medium-chain triglycerides.

When conservative management fails surgical intervention is then most often required.[15]

Fluorescein dye can aid in the localization of chyle leak.

Pleurodesis by surgical or chemical pleurodesis reduces the leakage of lymphatic fluids.

Octreotide has been shown to be beneficial and in some cases to stop the chylothorax after a few weeks.

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