CHYLOUS HEPATOHYDROTHORAX: A RARE CASE MANAGED USING A MULTIMODAL APPROACH

Abstract

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Chylothorax is a rare etiology of pleural effusion related to disruption of lymphatic drainage in thoracic duct or its tributaries. Chylous ascites is an even more rare finding associated with disruption of the abdominal lymphatic drainage usually associated with surgery, trauma, malignancy, and rarely cirrhosis. Chylothorax as a result of hepatohydrothorax physiology is an even less common finding (1). We present a case of a chylous hepatohydrothorax where we combined multiple treatment modalities to eliminate the pleural effusion. CASE PRESENTATION: A 60 year old female with a history of chronic hepatitis C and portopulmonary hypertension (PASP=75 mm Hg) presented with acute dyspnea and hypoxemia. Her chest X-ray demonstrated a large right pleural effusion (Figure 1). An urgent thoracentesis was performed with significant relief of symptoms; laboratory studies demonstrated a transudative chylous effusion (pleural protein = 2.1 g/dL, LDH = 44 U/L, and triglycerides (TG) = 486 mg/dL). A subsequent paracentesis confirmed concurrent chylous ascites (ascetic TG = 285 mg/dL). The subsequent day (hospital day 2), with rapid reaccumulation of the fluid, the patient developed increased respiratory distress and a chest tube was placed demonstrating the chylous hepatohydrothorax (Figure 2). The fluid was completely drained and the patient was kept NPO. Repeat fluid analysis at hospital day 5 revealed triglyceride level of 87 mg/dL; by day 10 the level had further decreased to 48 mg/dL. Low fat enteral nutrition was restarted, a Tenckhoff catheter was placed in the peritoneal space to control the ascites, and the chest tube output ceased with the tube removed on hospital day 10. Subsequent chest X-ray 1 week later showed no reaccumulation of the pleural fluid (Figure 3). She remained pleural effusion free for 3 months. DISCUSSION: Chylous ascites and chylothorax are both rare entities that can be difficult to manage (2). In this case, the etiology was postulated to be a hepatohydrothorax with migration of the fluid across the diaphragm. The mainstay for the treatment of nontraumatic chylothorax is drainage and dietary modifications. For chylous ascites, the main treatment is management of the liver cirrhosis (some studies demonstrating success after a transjugular intrahepatic portosystemic shunt procedure); dietary modification often being less successful (3). In this case, we demonstrated a very rapid resolution of triglyceride content after NPO status and were able to start low fat feeds without reaccumulation of chylous fluid; this finding demonstrated an apparent overlap in treatment options between chylothorax secondary to lymphatic drainage interruption and chylothorax secondary to cirrhotic processes. CONCLUSIONS: In all, chylous hepatohydrothorax is a rare entity that is difficult to manage; in this case, we combined the management modalities to control this patient's disease. Reference #1: Romero et al. Chylothorax in Cirrhosis of the Liver. CHEST 1998, 114: 154-159. Reference #2: Said et al. Chylous Ascites: Evaluation and Management. ISRN Hepatology, vol. 2014, Article ID 240473, 10 pages. Reference #3: de Vries et al. Cirrhosis related chylous ascites successfully treated with TIPS. Eur J Gastroenterol Hepatol, 2005;17(4):463. DISCLOSURES: No relevant relationships by Afshan Ahmed, source=Web Response No relevant relationships by Michael Bernstein, source=Web Response No relevant relationships by Lovin Pappy, source=Web Response