Bilateral Chylothorax Secondary to Cirrhosis and Chylous Ascites

Abstract

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Chylothorax is commonly caused by injury or obstruction of the thoracic duct within the thorax. Rarely, chylothorax can occur as a manifestation of decompensated liver disease with chylous ascites. CASE PRESENTATION: A 61 year old male with decompensated alcoholic liver disease was hospitalized for progressive dyspnea and abdominal distension. Physical examination and radiographic imaging identified large, bilateral pleural effusions and ascites. He did not respond to diuresis and therapeutic paracentesis, so bilateral thoracentesis was performed. Gross appearance of the bilateral pleural fluid was milky and amber in color, contrary to the expected appearance seen with transudative hepatic hydrothorax. Pleural fluid analysis was consistent with bilateral exudative chylothorax (triglycerides of 183 mg/dl and 197 mg/dl from the right and left, respectively). Pleural fluid to serum triglyceride ratio was 4.925 and cholesterol ratio was 0.333, definitively characterizing the pleural fluid as chyle. Although basic initial ascites fluid studies were consistent with portal hypertension as the mechanism, retrospective analysis was consistent with chylous ascites (triglycerides 148 mg/dl). Based on a MELD-Na of 26 and lack of responsiveness with aggressive medical management including diuretics, dietary modification, and abstinence from alcohol, the patient was referred for liver transplantation. DISCUSSION: The mechanism for chylothorax secondary to cirrhosis is due to portal hypertension causing rupture of small lymphatics and leakage of whole intestinal lymph into ascitic fluid, which then passes through diaphragmatic recesses. This mechanism is akin to the more commonly encountered hepatic hydrothorax which is typically transudative in nature. Management of chylothorax resulting from decompensated liver disease is similar to that of hepatic hydrothorax, although there are some additional considerations including use of octreotide to decrease lymphatic flow and post-prandial triglycerides, bowel rest with TPN, and use of orlistat. Medium-chain triglyceride supplementation, used in post-surgical chylous ascites, leads to increased hepatic encephalopathy and death in cirrhotic patients. CONCLUSIONS: For patients with cirrhosis, ascites, and pleural effusions, thoracentesis with thorough pleural fluid analysis can lead to accurate diagnosis of chylothorax, leading to appropriate identification and treatment. When suspected in patients with cirrhosis and ascites, pleural fluid studies should include triglycerides, cholesterol, and chylomicrons, in addition to serum cholesterol and triglycerides to allow for accurate recognition of chylothorax and the underlying etiology. Reference #1: Doerr, CH. “Etiology of Chylothorax in 203 Patients.” Mayo Clin Proc 80.7 (2005): 867-70. Print. Reference #2: Romero, S, and C Martin. “Chylothorax in Cirrhosis of the Liver: Analysis of Its Frequency and Clinical Characteristics.” Chest 114.1 (July 1998): 154-59. Print. DISCLOSURE: The following authors have nothing to disclose: Mark Nau, David Ferraro No Product/Research Disclosure Information