Question 24

With respect to chylothorax in the critically ill:

a)    Define chylothorax.    (10% marks)

b)    Outline how it should be diagnosed.    (40% marks)

c)    Describe the principles of management.    (50% marks)

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College answer

Not available.


This question is virtually identical to Question 5 from the first paper of 2019, except in 2019 diagnosis and management were rolled together into one big question worth 90% of the marks. If one inspects the marking rubric from 2019, one will note that the marks are allocated in the same way.

a) The definition of chylothorax:

  • Chylothorax is a pleural collection of fluid, where the fluid is positively identified as chyle by the presence of chylomicrons

b) Diagnosis of chylothorax:

Diagnostic methods (from Maladonado et al, 2009):

  • Gold standard: differential electrophoresis of pleural fluid to confirm chylomicrons
  • Sudan Red stain of chylomicrons in pleural fluid
  • Clinical identification of milky pleural fluid
  • Protein and LDH  in the pleural fluid is usually high
  • Pleural fluid triglyceride level is usually high
  • Fasting test and fat challenge (chylomicrons are only found in the circulation within 3 hours of eating and they disappear in the fasted state)
  • CT and lymphangiography 

c) Management of chylothorax from Bender et al (2015):

  • Conservative measures:

  • Surgical options:

    • Thoracic duct ligation (just proximal to the aortic hiatus)

    • Talc pleurodesis

    • Percutaneous lymphography and embolisation

    • Pleuroperitoneal shunt - where, for whatever reason, thoracic duct ligation is impossible


Fahimi, Hossein, et al. "Current management of postoperative chylothorax." The Annals of thoracic surgery 71.2 (2001): 448-450.

Fujita, Takeo, and Hiroyuki Daiko. "Efficacy and Predictor of Octreotide Treatment for Postoperative Chylothorax After Thoracic Esophagectomy." World Journal of Surgery (2014): 1-7.

Seriff, NATHAN S., et al. "Chylothorax: diagnosis by lipoprotein electrophoresis of serum and pleural fluid." Thorax 32.1 (1977): 98-100.

Hillerdal, G. "Chylothorax and pseudochylothorax." European Respiratory Journal 10.5 (1997): 1157-1162.

Shah, Rachit D., et al. "Postesophagectomy chylothorax: incidence, risk factors, and outcomes." The Annals of thoracic surgery 93.3 (2012): 897-904.

Merigliano, Stefano, et al. "Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation." The Journal of thoracic and cardiovascular surgery 119.3 (2000): 453-457.

Valentine, Vincent G., and Thomas A. Raffin. "The management of chylothorax." CHEST Journal 102.2 (1992): 586-591.

Nair, Sukumaran K., Matus Petko, and Martin P. Hayward. "Aetiology and management of chylothorax in adults." European journal of cardio-thoracic surgery 32.2 (2007): 362-369.

Hashim, Sami A., et al. "Treatment of chyluria and chylothorax with medium-chain triglyceride." New England Journal of Medicine 270.15 (1964): 756-761.

Maldonado, Fabien, et al. "Pleural fluid characteristics of chylothorax." Mayo Clinic Proceedings. Vol. 84. No. 2. Elsevier, 2009.

Light, Richard W., et al. "Pleural effusions: the diagnostic separation of transudates and exudates."Annals of Internal Medicine 77.4 (1972): 507-513.

McGrath, Emmet E., Zoe Blades, and Paul B. Anderson. "Chylothorax: aetiology, diagnosis and therapeutic options." Respiratory medicine 104.1 (2010): 1-8.

Shah, Rachit D., et al. "Postesophagectomy chylothorax: incidence, risk factors, and outcomes." The Annals of thoracic surgery 93.3 (2012): 897-904.

Ngan, H., M. Fok, and J. Wong. "The role of lymphography in chylothorax following thoracic surgery."The British journal of radiology 61.731 (1988): 1032-1036.

Buyukcelik, Mithat, et al. "An unusual cause of pleural effusion, urinothorax in a child with urinary stone disease." Pediatric Nephrology 20.10 (2005): 1487-1489.

Cellan-Jones, C. J., and William Murphy. "Traumatic chylothorax." British medical journal 2.4165 (1940): 590.

Watts, Stephen H. "Traumatic chylothorax." Annals of surgery74.6 (1921): 691.

Mishin, Igor, Gheorghe Ghidirim, and Marin Vozian. "Acute spontaneous chylous peritonitis: report of a case." Journal of Gastrointestinal & Liver Diseases 19.3 (2010).

Bender, Bradley, Vijayashree Murthy, and Ronald S. Chamberlain. "The changing management of chylothorax in the modern era." European Journal of Cardio-Thoracic Surgery 49.1 (2015): 18-24.

Guillem, Philippe, et al. "Etilefrine use in the management of post-operative chyle leaks in thoracic surgery." Interactive Cardiovascular and thoracic surgery 3.1 (2004): 156-160.

Itkin, Maxim, et al. "Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients." The Journal of thoracic and cardiovascular surgery 139.3 (2010): 584-590.