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Chylothorax

Venous return · detail · TG > 1.24 mmol/L

Leak of chyle from a torn or obstructed thoracic duct into the pleural space. Because the duct crosses the midline at about T5, an injury below that level gives a right-sided effusion and an injury above it a left-sided one.

Traced from the start

  1. Testis and ovary
  2. Lower limb, scrotum and perineal skin
  3. Para-aortic (lumbar) nodesSuperficial and deep inguinal nodes
  4. Gut and abdominal viscera
  5. Preaortic nodes (coeliac, superior and inferior mesenteric)
  6. Head and neck
  7. Deep cervical nodesLeft supraclavicular (Virchow's) node
  8. Upper limbBreast
  9. Axillary nodes
  10. Lungs and thoracic viscera
  11. Tracheobronchial and mediastinal nodesParasternal (internal mammary) nodes
  12. Right and left lumbar trunksIntestinal trunkJugular lymph trunksSubclavian lymph trunksBronchomediastinal trunks
  13. Thoracic duct
  14. Chylothorax

Detail

Diagnostic fluid
Triglycerides above 1.24 mmol/L (110 mg/dL), or chylomicrons present
Effectively excluded by
Triglycerides below 0.56 mmol/L (50 mg/dL)
Injury below T5
Right chylothorax
Injury above T5
Left chylothorax
Commonest causes
Iatrogenic (oesophagectomy, cardiothoracic and neck surgery); lymphoma leads the non-traumatic causes
First-line management
Drainage plus a low-fat, medium-chain triglyceride diet or parenteral nutrition, with octreotide
Surgery
Thoracic duct ligation or embolisation if output stays above about 1 L/day

When it goes wrong

Continuing loss of chyle

Hypoalbuminaemia, malnutrition and T-lymphocyte depletion with immunosuppression

Cholesterol-rich effusion of chronic tuberculosis or rheumatoid disease

Pseudochylothorax, distinguished by high cholesterol with low triglycerides

Practise this structure

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