Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of chylothorax

John E Heffner, MD
Section Editor
V Courtney Broaddus, MD
Deputy Editor
Geraldine Finlay, MD


Chylothorax is caused by disruption or obstruction of the thoracic duct or its tributaries that results in leakage of chyle (lymphatic fluid of intestinal origin) into the pleural space. Chylous ascites can also flow into the pleural space. The fluid typically has a high triglyceride content and often a turbid or milky white appearance. In contrast, a cholesterol pleural effusion, which can also have a milky appearance, has a high concentration of cholesterol and lecithin-globulin complexes that accumulate due to pleural inflammation or infection.

A pleural fluid triglyceride concentration greater than 110 mg/dL (1.24 mmol/L) strongly supports the diagnosis of a chylothorax, but triglyceride concentrations may be less than 110 mg/dL in 15 percent of patients and less than 50 mg/dL in 3 percent [1]. If the triglyceride level is less than 110 mg/dL (less than 1.24 mmol/L) but the diagnosis is suspected clinically, the presence of chylomicrons in the pleural fluid by lipoprotein analysis can confirm the presence of a chylothorax.

The therapeutic options and an approach to managing chylothorax will be reviewed here. The etiology, clinical presentation, and diagnosis of chylothorax, the evaluation and management of cholesterol effusions, and general issues regarding the evaluation and treatment of pleural effusions are discussed separately. (See "Etiology, clinical presentation, and diagnosis of chylothorax" and "Clinical presentation, diagnosis and management of cholesterol effusions" and "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Imaging of pleural effusions in adults" and "Mechanisms of pleural liquid accumulation in disease".)


Many interventions have been used to treat chylothorax, including treatment of the underlying disease, pleural drainage, dietary modifications, pleurodesis, and thoracic duct ligation. More rarely-used modalities include somatostatin/octreotide, midodrine, sirolimus, pleurovenous or pleuroperitoneal shunting, therapeutic lymphangiography, and thoracic duct embolization or disruption. Staged approaches for using the various options based on the etiology of the chylothorax are discussed in the following sections. (See 'Management approach' below.)

Treatment of the underlying condition — Among patients with chylothorax due to nontraumatic causes, such as infection, sarcoidosis, lymphoma, or metastatic carcinoma, treatment of the underlying condition is an important component of therapy, either alone or combined with other modalities depending on the severity of chyle leakage and rapidity of response to therapy. (See 'Nontraumatic chylothorax' below.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Feb 19, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Maldonado F, Hawkins FJ, Daniels CE, et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009; 84:129.
  2. Wasmuth-Pietzuch A, Hansmann M, Bartmann P, Heep A. Congenital chylothorax: lymphopenia and high risk of neonatal infections. Acta Paediatr 2004; 93:220.
  3. Orange JS, Geha RS, Bonilla FA. Acute chylothorax in children: selective retention of memory T cells and natural killer cells. J Pediatr 2003; 143:243.
  5. Franksson C, Lundgren G, Magnusson G, Ringdén O. Drainage of thoracic duct lymph in renal transplant patients. Transplantation 1976; 21:133.
  6. Merrigan BA, Winter DC, O'Sullivan GC. Chylothorax. Br J Surg 1997; 84:15.
  7. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997; 84:1711.
  8. Sriram K, Meguid RA, Meguid MM. Nutritional support in adults with chyle leaks. Nutrition 2016; 32:281.
  9. Jensen GL, Mascioli EA, Meyer LP, et al. Dietary modification of chyle composition in chylothorax. Gastroenterology 1989; 97:761.
  10. Densupsoontorn NS, Jirapinyo P, Wongarn R, et al. Management of chylothorax and chylopericardium in pediatric patients: experiences at Siriraj Hospital, Bangkok. Asia Pac J Clin Nutr 2005; 14:182.
  11. Machado JD, Suen VM, Marchini JS. Is oral nutritional therapy effective for the treatment of chylothorax? A case report. Nutrition 2008; 24:607.
  12. Takuwa T, Yoshida J, Ono S, et al. Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg 2013; 146:571.
  13. Martucci N, Tracey M, Rocco G. Postoperative Chylothorax. Thorac Surg Clin 2015; 25:523.
  14. Weissberg D, Ben-Zeev I. Talc pleurodesis. Experience with 360 patients. J Thorac Cardiovasc Surg 1993; 106:689.
  15. Vargas FS, Milanez JR, Filomeno LT, et al. Intrapleural talc for the prevention of recurrence in benign or undiagnosed pleural effusions. Chest 1994; 106:1771.
  16. Graham DD, McGahren ED, Tribble CG, et al. Use of video-assisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 1994; 57:1507.
  17. Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH. Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci 2010; 339:314.
  18. Mares DC, Mathur PN. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series. Chest 1998; 114:731.
  19. Paul S, Altorki NK, Port JL, et al. Surgical management of chylothorax. Thorac Cardiovasc Surg 2009; 57:226.
  20. Griffo S, De Luca G, Stassano P. Chylothorax after abdominal surgery. Gen Thorac Cardiovasc Surg 2010; 58:159.
  21. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 2010; 104:1.
  22. Liu M, Wu B, Cui Y, et al. Surgical treatment of chylothorax caused by lymphangioleiomyomatosis. J Thorac Dis 2014; 6:E11.
  23. Miao L, Zhang Y, Hu H, et al. Incidence and management of chylothorax after esophagectomy. Thorac Cancer 2015; 6:354.
  24. Fahimi H, Casselman FP, Mariani MA, et al. Current management of postoperative chylothorax. Ann Thorac Surg 2001; 71:448.
  25. Shimizu K, Yoshida J, Nishimura M, et al. Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J Thorac Cardiovasc Surg 2002; 124:499.
  26. Zabeck H, Muley T, Dienemann H, Hoffmann H. Management of chylothorax in adults: when is surgery indicated? Thorac Cardiovasc Surg 2011; 59:243.
  27. Le Pimpec-Barthes F, D'Attellis N, Dujon A, et al. Chylothorax complicating pulmonary resection. Ann Thorac Surg 2002; 73:1714.
  28. Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31:743.
  29. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007; 32:362.
  30. Wurnig PN, Hollaus PH, Ohtsuka T, et al. Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg 2000; 70:1662.
  31. Kos S, Haueisen H, Lachmund U, Roeren T. Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage. Cardiovasc Intervent Radiol 2007; 30:968.
  32. Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52:305.
  33. Hayden JD, Sue-Ling HM, Sarela AI, Dexter SP. Minimally invasive management of chylous fistula after esophagectomy. Dis Esophagus 2007; 20:251.
  34. Cerfolio RJ, Allen MS, Deschamps C, et al. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996; 112:1361.
  35. Lyon S, Mott N, Koukounaras J, et al. Role of interventional radiology in the management of chylothorax: a review of the current management of high output chylothorax. Cardiovasc Intervent Radiol 2013; 36:599.
  36. Cope C. Management of chylothorax via percutaneous embolization. Curr Opin Pulm Med 2004; 10:311.
  37. Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol 1999; 10:1248.
  38. Hoffer EK, Bloch RD, Mulligan MS, et al. Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct. AJR Am J Roentgenol 2001; 176:1040.
  39. Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13:1139.
  40. Boffa DJ, Sands MJ, Rice TW, et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg 2008; 33:435.
  41. Marcon F, Irani K, Aquino T, et al. Percutaneous treatment of thoracic duct injuries. Surg Endosc 2011; 25:2844.
  42. Itkin M, Kucharczuk JC, Kwak A, et al. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010; 139:584.
  43. Pamarthi V, Stecker MS, Schenker MP, et al. Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. J Vasc Interv Radiol 2014; 25:1398.
  44. Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: experience in 34 patients. Chest 2013; 143:158.
  45. Itkin M. Lymphatic intervention is a new frontier of IR. J Vasc Interv Radiol 2014; 25:1404.
  46. Gómez FM, Martínez-Rodrigo J, Martí-Bonmatí L, et al. Transnodal lymphangiography in the diagnosis and treatment of genital lymphedema. Cardiovasc Intervent Radiol 2012; 35:1488.
  47. Laslett D, Trerotola SO, Itkin M. Delayed complications following technically successful thoracic duct embolization. J Vasc Interv Radiol 2012; 23:76.
  48. Kawasaki R, Sugimoto K, Fujii M, et al. Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment. AJR Am J Roentgenol 2013; 201:659.
  49. Matsumoto T, Yamagami T, Kato T, et al. The effectiveness of lymphangiography as a treatment method for various chyle leakages. Br J Radiol 2009; 82:286.
  50. Lee EW, Shin JH, Ko HK, et al. Lymphangiography to treat postoperative lymphatic leakage: a technical review. Korean J Radiol 2014; 15:724.
  51. Liou DZ, Warren H, Maher DP, et al. Midodrine: a novel therapeutic for refractory chylothorax. Chest 2013; 144:1055.
  52. Taveira-DaSilva AM, Hathaway O, Stylianou M, Moss J. Changes in lung function and chylous effusions in patients with lymphangioleiomyomatosis treated with sirolimus. Ann Intern Med 2011; 154:797.
  53. Kalomenidis I. Octreotide and chylothorax. Curr Opin Pulm Med 2006; 12:264.
  54. Al-Zubairy SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother 2003; 37:679.
  55. Kelly RF, Shumway SJ. Conservative management of postoperative chylothorax using somatostatin. Ann Thorac Surg 2000; 69:1944.
  56. Markham KM, Glover JL, Welsh RJ, et al. Octreotide in the treatment of thoracic duct injuries. Am Surg 2000; 66:1165.
  57. Demos NJ, Kozel J, Scerbo JE. Somatostatin in the treatment of chylothorax. Chest 2001; 119:964.
  58. Evans J, Clark MF, Mincher L, Varney VA. Chylous effusions complicating lymphoma: a serious event with octreotide as a treatment option. Hematol Oncol 2003; 21:77.
  59. Mohseni-Bod H, Macrae D, Slavik Z. Somatostatin analog (octreotide) in management of neonatal postoperative chylothorax: is it safe? Pediatr Crit Care Med 2004; 5:356.
  60. Mincher L, Evans J, Jenner MW, Varney VA. The successful treatment of chylous effusions in malignant disease with octreotide. Clin Oncol (R Coll Radiol) 2005; 17:118.
  61. Paget-Brown A, Kattwinkel J, Rodgers BM, Michalsky MP. The use of octreotide to treat congenital chylothorax. J Pediatr Surg 2006; 41:845.
  62. Roehr CC, Jung A, Proquitté H, et al. Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review. Intensive Care Med 2006; 32:650.
  63. Hillerdal G. Yellow nail syndrome: treatment with octreotide. Clin Respir J 2007; 1:120.
  64. Ando K, Kurihara M, Kataoka H, et al. Efficacy and safety of low-dose sirolimus for treatment of lymphangioleiomyomatosis. Respir Investig 2013; 51:175.
  65. Tanaka E, Matsumoto K, Shindo T, Taguchi Y. Implantation of a pleurovenous shunt for massive chylothorax in a patient with yellow nail syndrome. Thorax 2005; 60:254.
  66. Gupta D, Ross K, Piacentino V 3rd, et al. Use of LeVeen pleuroperitoneal shunt for refractory high-volume chylothorax. Ann Thorac Surg 2004; 78:e9.
  67. Fremont RD, Milstone AP, Light RW, Ninan M. Chylothoraces after lung transplantation for lymphangioleiomyomatosis: review of the literature and utilization of a pleurovenous shunt. J Heart Lung Transplant 2007; 26:953.
  68. Artemiou O, Marta GM, Klepetko W, et al. Pleurovenous shunting in the treatment of nonmalignant pleural effusion. Ann Thorac Surg 2003; 76:231.
  69. Epaud R, Dubern B, Larroquet M, et al. Therapeutic strategies for idiopathic chylothorax. J Pediatr Surg 2008; 43:461.
  70. Luks V, Aljohaney A, Amjadi K. Tunneled pleural catheters in the management of chylothorax from central venous catheter-related superior vena cava obstruction. Respiration 2013; 86:67.
  71. Agrawal V, Sahn SA. Lipid pleural effusions. Am J Med Sci 2008; 335:16.
  72. Jarman PR, Whyte MK, Sabroe I, Hughes JM. Sarcoidosis presenting with chylothorax. Thorax 1995; 50:1324.
  73. Roy, PH, Carr, DT, Payne, WS. The problem of chylothorax. Mayo Clin Proc 1967; 42:457.
  74. O'Callaghan AM, Mead GM. Chylothorax in lymphoma: mechanisms and management. Ann Oncol 1995; 6:603.
  75. Iqbal MH, Smith PR, Bande S. Chylothorax due to angioimmunoblastic T-cell lymphoma. Intern Med J 2009; 39:67.
  76. Ferguson MK. Thoracoscopy for empyema, bronchopleural fistula, and chylothorax. Ann Thorac Surg 1993; 56:644.
  77. Martínez Brocca MA, García García-Doncel L, Pereira Cunill JL, et al. [Nutritional support in chylothorax secondary to lymphoma]. Nutr Hosp 2002; 17:43.
  78. Asuquo BJ, Gould GA. Recurrent chylothorax in a patient with non-Hodgkins lymphoma: case report. East Afr Med J 2004; 81:215.
  79. Milsom JW, Kron IL, Rheuban KS, Rodgers BM. Chylothorax: an assessment of current surgical management. J Thorac Cardiovasc Surg 1985; 89:221.
  80. Jimenez CA, Mhatre AD, Martinez CH, et al. Use of an indwelling pleural catheter for the management of recurrent chylothorax in patients with cancer. Chest 2007; 132:1584.
  81. Marts BC, Naunheim KS, Fiore AC, Pennington DG. Conservative versus surgical management of chylothorax. Am J Surg 1992; 164:532.
  82. Sudduth CD, Sahn SA. Pleurodesis for nonmalignant pleural effusions. Recommendations. Chest 1992; 102:1855.
  83. Ferguson MK, Little AG, Skinner DB. Current concepts in the management of postoperative chylothorax. Ann Thorac Surg 1985; 40:542.
  84. Patterson GA, Todd TR, Delarue NC, et al. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981; 32:44.
  85. Rubin JW, Moore HV, Ellison RG. Chylothorax: therapeutic alternatives. Am Surg 1977; 43:292.
  86. Zoetmulder F, Rutgers E, Baas P. Thoracoscopic ligation of a thoracic duct leakage. Chest 1994; 106:1233.
  87. Terzi A, Furlan G, Magnanelli G, et al. Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication. Thorac Cardiovasc Surg 1994; 42:81.
  88. Shimizu K, Otani Y, Ibe T, et al. Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer. Jpn J Thorac Cardiovasc Surg 2005; 53:39.
  89. Cho HJ, Kim DK, Lee GD, et al. Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg 2014; 97:408.
  90. Akin H, Olcmen A, Isgorucu O, et al. Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg 2012; 60:135.
  91. Cerfolio RJ. Chylothorax after esophagogastrectomy. Thorac Surg Clin 2006; 16:49.
  92. Sarsam MA, Rahman AN, Deiraniya AK. Postpneumonectomy chylothorax. Ann Thorac Surg 1994; 57:689.
  93. Shirai T, Amano J, Takabe K. Thoracoscopic diagnosis and treatment of chylothorax after pneumonectomy. Ann Thorac Surg 1991; 52:306.
  94. Yadav H, Nolan ME, Nichols FC 3rd, Daniels CE. Tension chylothorax following pneumonectomy. Respir Med Case Rep 2015; 14:16.