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| CASE REPORT |
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| Year : 1991 | Volume
: 37
| Issue : 4 | Page : 222-4 |
Chylothorax--a conservative approach (a case report).
Oak SN, Kulkarni BK, Deshmukh H, Kamble M, Borwankar SS
Department of Paediatric Surgery, Seth G. S. Medical College, Parel, Bombay, Maharashtra.
Correspondence Address:
Department of Paediatric Surgery, Seth G. S. Medical College, Parel, Bombay, Maharashtra.
Lymphatic blockage due to a non-specific inflammation probably of a filarial origin caused dilatation and ectasia of lymph channels at thoracic inlet of a child. Transudation of lymph through these channels led to chylothorax. The present case report highlights the significance of conservative approach towards this complex problem.
How to cite this article:
Oak S N, Kulkarni B K, Deshmukh H, Kamble M, Borwankar S S. Chylothorax--a conservative approach (a case report). J Postgrad Med 1991;37:222 |
How to cite this URL:
Oak S N, Kulkarni B K, Deshmukh H, Kamble M, Borwankar S S. Chylothorax--a conservative approach (a case report). J Postgrad Med [serial online] 1991 [cited 2021 Feb 26];37:222. Available from: https://www.jpgmonline.com/text.asp?1991/37/4/222/752 |
When chyle accumulates in a pleural space, the situation may be life- threatening, especially in a child. Respiratory embarrassment may be significant, but malnutrition and debility secondary to loss of chyle pose a much more serious hazard. We present here, a case report of a chylothorax of filarial origin and stress on the conservative approach of management.
An eight-year-old boy weighing 24.6 kg. was referred to Department of Paediatric Surgery, King Edward Memorial Hospital, Mumbai with complaints of dyspnoea, orthopnoea, weight loss and fever. The patient came front a non-endemic zone of filariasis in Maharashtra. He was admitted and investigated at a District General Hospital, where a plain x-ray chest had revealed homogenous opacity in (left) hemithorax, shift of mediastinum to right and downward displacement of left half of diaphragm. A diagnostic paracentesis had revealed milky-white fluid and hence left chylothorax was suspected.
Haemogram and other blood investigations repeated in King Edward Memorial Hospital revealed anaemia, hypoalbuminemia and leucocytosis. Eosinophilic count was within normal limits. X-ray chest and diagnostic tap revealed milky fluid, which was sent for analysis. Milky fluid was sterile on culture and electrophoresis showed a heavy band of chylomicrons, thereby establishing its chylous nature. The patient was dyspnoeic and in order to reduce respiratory embarrassment, a portex intercostal drainage tube (No. 20) was introduced in left pleural cavity. On the first day, the drainage volume was nearly 1.2 litres, which continued to be more than 750- 900 ml for next 15 days. He was put on parenteral nutrition, consisting of 20% intralipid, intravenous aminoplasma and 10% dextrose solutions. He was kept nil by mouth for initial 6 days and later, on high protein, low fat medium chain triglyceride (M.C.T.) containing diet. Blood and fresh frozen plasma infusion were given.
Intercostal drainage catheter drained copious volume of chyle for nearly 23 days and then the quantity of daily drainage dropped to about 200 ml every day. A pedal lymphangiogram was done to evaluate the status of thoracic duct, cisterna chylii and identify the site of possible leak and to demonstrate lymphatic anatomy. Lymphangiogram revealed passage of 'Lipiodal' through limbs and abdominal lymphatics without any hindrance. The cisterna chylli and thoracic duct were not opacified at the thoracic inlet. Lymphnodes at the thoracic inlet appeared large. (See [Figure - 1]) Small globules of the contrast were seen in left pleural space. (See [Figure - 2]) but no localised fistula was seen. Evidently transudation of chyle had been occurring from the mediastinal lymphatics with obstruction of thoracic duct at the inlet.
Conservative treatment policy with intercostal drainage, parenteral nutrition and low-fat, protein rich diet was continued. Diethylcarbamazine was added in a dosage of 6 mg/kg/day. Chylothorax resolved after 45 days; intercostal drain was removed and the patient was discharged on a long-term diethylcarbamazine treatment. He was subsequently followed up at 3 monthly interval for one year and did not show a recurrence of chylothorax.
Chylothorax is a life-threatening form of pleural effusion in the childhood. Its aetiology may be either a congenital abnormality of the thoracic duct, traumatic (post-operative and non-surgical) and non-traumatic[1].
Congenital chylothorax may be due either to rupture during delivery of a localized congenital weakness in the duct, or to lymphatico-pleural fistula[7]. Chylothorax is one of the most common pleural effusions encountered in first few days of life[2]. Prior to milk feedings, chyle is golden and transparent like "dilute orange juice". Post-operative chylo-thorax is seen after operations like Blalock-Taussing shunt or patent ductus arteriosus ligations. Even trivial trauma like coughing or weight lifting may sometimes lead to rupture the duct and cause chylothorax[8]. Cases of non-traumatic chylothorax include neoplasm, aneurysm, inflammatory diseases and sub-clavian vein thrombosis[1].
Since large losses of chyle may have a devastating effect in a child, nutritional support either by parenteral hyperalimentation or a MCT diet, becomes necessary. MCT diet would appear preferable to hyperalimentation, as it eliminates the risk of infection and is less expensive. Dietary fats are absorbed through intestinal mucosa, in the form of glycerol and fatty acids. Long chain fatty acids are re-esterified and passed into lymph as chylomicrons, whereas medium chain fatty acids (10-Or- fewer carbon atoms) pass directly into portal venous blood.
Current regimens reported for the treatment of chylo-thorax suggest a 2- to 4-weeks trial of conservative therapy, during which chyle collections are removed by repeated thoraco-centesis or tube thoracostomy. Mcfarlane and Holman[6] suggest addition of digitalis and diuretics. Williams and Burford[9] advice bed rest and avoiding of cough, straining and laughing[2]. Gingell[3] suggested pleurodesis with insufflation of iodized talc via intrapleural tube. Kirkland [5] has tried a pleuro-venous shunt. In most of the cases fistula closes without operation. Thoracotomy is indicated for:
1. continued reaccumulation of chyle after a 3-4 weeks conservative treatment,
2. progressive weight loss and debility on conservative regimen.
Randolph and gross [7] suggest ligation of leaking vessel wherever possible or ligation of main duct above and below the leak, when the exact site of leakage cannot be determined.
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