Milky pleural fluid post-thoracic surgery or in lymphoma, suspected chylothorax
Recommended: Pleural fluid analysis (triglycerides > 110 mg/dL); lymphangiogram or MR lymphangiography if intervention planned is the preferred imaging study for milky pleural fluid post-thoracic surgery or in lymphoma, suspected chylothorax. Triglycerides > 110 mg/dL or chylomicrons confirm chylothorax.
Recommended study
Pleural fluid analysis (triglycerides > 110 mg/dL); lymphangiogram or MR lymphangiography if intervention planned
Triglycerides > 110 mg/dL or chylomicrons confirm chylothorax. Etiologies: post-thoracic / cardiac surgery, lymphoma, lymphatic malformation.
If the default doesn't apply
Thoracic duct embolization planning
XR
Intranodal lymphangiography (lipiodol injection of inguinal nodes)
IV contrast
Watch-outs
Nutritional / immune consequences
Chyle loss → lymphocytopenia, hypoalbuminemia, fat-soluble vitamin loss. NPO with TPN or MCT diet.
Mass cause
Look for mediastinal mass / lymphoma — image with CT chest with contrast.
Pearls
- Pseudo-chylothorax (cholesterol effusion): elevated cholesterol, normal triglycerides, chronic effusion.
- Thoracic duct courses on right then crosses at T5 — left-sided chylothorax usually distal injury.
- IR thoracic duct embolization is increasingly first-line for high-output leaks.