SESSION TITLE: Miscellaneous Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: The differential diagnosis of a pleural effusion includes a diverse group of disorders. We present the case of a rare cause of a transudative chylothorax.
CASE PRESENTATION: A 55 year-old morbidly obese man with a history of alcoholic cirrhosis, complicated by ascites and encephalopathy, presented with a subacute onset of shortness of breath. Physical exam revealed absent breath sounds on the right. Chest radiography revealed complete opacification of the right hemi-thorax. Thoracentesis revealed transudative milky fluid with triglycerides of 200mg/dL, consistent with chylothorax. CT chest/abdomen/pelvis was done to evaluate the thoracic and right lymphatic ducts. No abnormalities were noted, though, ascites was seen. Paracentesis revealed a high SAAG fluid with triglycerides of 174mg/dL, consistent with chylous ascites.
DISCUSSION: Most chylothoraces are exudative (86% vs 14% transudative),1 and the majority are secondary to trauma, surgery or obstruction from malignancy. Transudative chylothoraces are uncommon and most often due to cirrhosis.1 These chylothoraces collect secondary to translocation of chylous ascites across the diaphragm.2 Chylous ascites may form via elevated portal pressures and lymphatic degenerative changes.2 Medium chain triglycerides (MCTs) and octreotide can be used to curb the formation and uptake/transport of chylomicrons, respectively. Transjugular intrahepatic portosystemic shunt (TIPS) can be considered in patients with cirrhosis and chylothoraces, though, no controlled studies have evaluated the success of TIPS in this group.3 Our patient was considered for TIPS, though, the finding of hepatocellular carcinoma complicated his course and prognosis. He was medically managed with MCTs and Octreotide.
CONCLUSIONS: The differential diagnosis of a transudative chylothorax is an important group of diseases to consider. Securing the diagnosis of a chylous effusion due to a hepatic source is essential as treatment may include dietary, pharmacologic and invasive interventions.
Reference #1: Maldonado F, et al. Pleural Fluid Characteristics of Chylothorax. Mayo Clinic Proceedings 2009;84(2):129-133
Reference #2: Diaz-Guzman E, et al. Transudative Chylothorax: Report of Two Cases and Review of the Literature. Lung (2005);183:169-175
Reference #3: Lutz P, et al. Transjugular Intrahepatic Portosystemic Shunt in Refractory Chylothorax Due to Liver Cirrhosis. World J of Gastroenterology 2013;19(7):1140-1142
DISCLOSURE: The following authors have nothing to disclose: Gabriel Gomez, Keren Fogelfeld, Dennis Yick, Nader Kamangar
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