Morning Report 6/28 – Chylothorax

Some highlights about chylothorax from Amy’s great morning report case.

Chylothorax (picture from StatPearls:https://www.ncbi.nlm.nih.gov/books/NBK459206/)

• Equal incidence of traumatic (during surgery in chest) vs non-traumatic (malignancy causing compression or lymphoma, also lots of idiopathic/misc causes)
• Gold standard: chylomicrons in fluid – lipoprotein electrophoresis but this is often not available
• Cutoff: using triglycerides as surrogate, TG>110 mg/dL very likely chylothorax, TG<50 very unlikely to be chylothorax
• Gross appearance of fluid not that sensitive for diagnosis, less than half of cases have the classic milky appearance
• IR lymphagiogram – injecting lipophilic contrast agent into a lymph node and watching it ascend into the abdomen to identify the cisterna chyli
• Recommendations: special diet ultra-low in middle chain fatty acids (<10g per day, aka less than one piece of pizza, 3 pieces of bacon, and dove chocolate bar) – decreased chylomicrons > decreased chyle
• Other options include thoracic duct embolization, ligation (especially for high-volume chyle leak from thoracic duct injury), pleurodesis, pleuroperitoneal shunt, octreotide, somastatin etc

Sources:

Amy Ludwig’s Morning Report

StatPearls: Chylothorax