etiology , diagnosis , treatment

1. CHYLOTHORAX
 By
DR.VIJAYANAND PALANISAMY

2. Thoracic duct
- Is the largest lymphatic trunk which
drains chyle(product of fat digestion) &
most lymph of body.
- Extent- Upper abdomen at lower
border of T12 to lower part of neck,
crossing post & sup mediastinum
- 45cms long & 0.5cms wide
- Appears Beaded due to presence of
many valves in its lumen
2

3. Drains lymph from whole of body except
• Rt side of head & neck
• Rt upper limb
• Rt lung & thoracic wall
• Rt side of heart and rt surface of liver
AREA OF DRAINAGE
3

5.  COURSE:
* BEGINS IN ABDOMEN AT LOWER BORDER
OF T12 AS A CONTINUATION OF CISTERNA
CHYLI
* ENTERS POST MEDIASTINUM THROUGH
AORTIC OPENING OF DIAPHRAGM(T12)
* AT T5 SHIFTS TO LEFT & RUNS IN
SUPERIOR MEDIASTINUM
* AT C7 (ROOT OF NECK) ARCHES
LATERALLY, THEN DOWNWARDS
* ENDS AT ANGLE FORMED BY UNION OF
LEFT INT JUGULAR VEIN & LT SUBCLAVIAN
VEIN, (REGURGE OF BLOOD PREVENTED BY A
PAIR OF VALVES)

6. COMPOSITION OF CHYLE
 Lipids - 60% to 70% of ingested fat absorbed by
intestinal lymphatics.
 Proteins
 Electrolytes
 Cellular Elements
 Miscellaneous Elements - Fat soluble vitamins,
antibodies, urea nitrogen, and enzymes

7. CHYLOTHORAX
 A chylothorax (or chyle leak) is a type of pleural
effusion. It results from lymph formed in the
digestive system called chyle accumulating in the
pleural cavity due to either disruption or obstruction
of the thoracic duct.
 In a normal adult, the thoracic duct transports up to
4 L of chyle per day, allowing a rapid and large
accumulation of fluid in the chest
 The prevalence after various cardiothoracic
surgeries is 0.2-1%.

8. CHYLOMA
 a collection of chyle below the pleura develops
when the thoracic duct first leaks
 severe chest pain, dyspnoea and tachycardia

9. AETIOLOGY

10.  subclavian vein catheterisation and duct blockage
due to central venous catheterisation related
venous thrombosis
 Yellow nail syndrome-bronchiectasis, sinusitis ,
hypoplastic lymphatics, yellow nails (due to slow
growth), lymphoedema, particularly of the lower
limbs and pleural effusions

11. SIGNS AND SYMPTOMS
 Hypovolaemia
 Respiratory difficulty
 malnutrition due to the loss of protein, fats and
vitamins - weight loss and muscle wasting
 hyponatraemia and hypocalcaemia
 Immunosuppression
 Empyema is a rare due to bacteriostatic nature of
lecithin and fatty acids
 Decreased breath sounds
 Shifting dullness

12.  Congenital Chylothorax-Fluid
initially clear but turns turbid with
milk feeding

13.  The effusion may be unilateral, either right (50%) or
left sided (33.3%), or bilateral (16.66%) and is
dependent on the location of the leak. Damage to
the duct above the fifth thoracic vertebra results in a
left sided effusion whereas damage to the duct
below this level leads to a right sided effusion

14. INVESTIGATION
 confirmation of the diagnosis by fluid analysis
 identification of the leakage point
 Investigation should continue until the aetiology

15.  fluid will not always be milky or white
and may for example be blood stained
after trauma or even serious in
appearance if the patient is fasting
 Collecting the fluid into an EDTA tube
allows for cell counts on the sample.

16.  thoracentesis and laboratory analysis of the pleural
fluid
 centrifugation of pleural fluid
 adding 1-2 ml of ethylether
 fluid stained with Sudan III

17. LEFT SIDED EFFUSIONS

18.  CT abdomen and thorax
 Lymphangiograph 
 High fat content feed mixed
with methylene blue

19. BIOCHEMICAL DIAGNOSIS OF CHYLOTHORAX
 pleural fluid triglyceride of >110 mg/dl had a 1%
chance of being non-chylous and that a triglyceride
of <50 mg/dl had a 5% chance of being chylous.
 As a result, pleural fluid triglyceride levels>1.24
mmol/l (110 mg/dl) with a cholesterol<5.18 mmol/l
(200 mg/dl) is diagnostic of chylothorax

20. PSEUDOCHYLOTHORAX
 tuberculous pleurisy, chronic pneumothorax,
rheumatoid pleurisy, poorly evacuated empyema
and chronic haemothorax

22.  Treatment is initially conservative:
1. Tube drainage.
2. Medium-chain fatty acid diet.
3. Fluid and electrolyte support.
4. NPO and TPN
5. Somatostatin
 Failure of conservative treatment requires
surgical solution

23. OPERATIVE TECHNIQUES
 Direct ligation of thoracic duct
 Supradiaphragmatic mass ligation of the thoracic
duct
 Video Assisted Thoracic Surgery (VATS)
 ‡‡Pleurodesis
 Fibrin glue

24. DIAGNOSTIC CONSIDERATIONS
 Timing of surgical management is controversial and
depends on the etiology of the chylothorax and the
patient's overall condition.
 Patients with postesophagectomy chylothorax have
a 50-82% mortality rate if treated conservatively.
 A malignant etiology of the chylothorax must be
ruled out, as greater than 50% of cases are due to
malignancy, of which lymphoma accounts for
approximately 75% of cases, followed by lung
carcinoma.

25. ETIOLOGICAL TREATMENT
 sarcoidosis with steroids
 cardiac failure with diuretics
 Malignancy with radiotherapy or chemotherapy if no
improvement then pleurodesis

26.  If the leak is in the
region of the neck or
upper thorax, the
thoracic duct is ligated
in the area known as
Poirier’s triangle
between the arch of
the aorta, internal
carotid and vertebral
column

27.  Ligation of the thoracic duct is
successful in 90% of patients
when performed just above
the right hemi-diaphragm

28. VATS FOR LIGATION OF THORACIC
DUCT

29. THORACIC DUCT EMBOLIZATION
-EMBOLIZATION PERFORMED BY COILS AND GELATIN
SPONGE

30.  too unfit for major surgery or have malignancy, a
pleuroperitoneal shunt may be useful .
complications such as infection, adhesions, and
clogging of the implants
 1% Evans blue dye can either be injected into the
web space of the toes for uptake into the lymphatic
space to increase visualization.

31. THANK
U