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Management of chylothorax

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


Chylothorax is typically 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. Leakage of chyle from abnormal lymphatic masses and lymphatic malformations and flow of chylous ascites into the pleural space can also cause chylothorax. 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]. A pleural fluid triglyceride concentration less than 50 mg/dL provides strong support that the patient does not have a chylothorax. 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 electrophoresis 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 recently, modalities such as somatostatin/octreotide, sirolimus, pleurovenous or pleuroperitoneal shunting, therapeutic lymphangiography, and thoracic duct embolization or disruption have assumed roles in management. It is critical to exclude chylous ascites as the cause of chylothorax because the transdiaphragmatic migration of ascites may not respond to interventions directed toward altering lymph flow in the thoracic duct [2]. 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.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 13, 2017.
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