ISOLATED CHYLOTHORAX IN LIVER CIRRHOSIS

Abstract

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Hepatic hydrothorax, commonly seen in cirrhotic portal hypertension occurs from the movement of ascitic fluid into the pleural space across microscopic defects in the diaphragm due to the negative intrapleural pressure. Liver cirrhosis causing chylothorax is extremely rare accounting for only about 1% cases. CASE PRESENTATION: We present a 43-year-old female with recurrent hepatic hydrothorax from decompensated alcoholic cirrhosis complicated by hepatic encephalopathy. She was admitted to the intensive care unit for airway monitoring. Patient was evaluated by Hepatology in the past and deemed not a liver transplant candidate due to severe malnutrition. She gets frequent thoracentesis and paracentesis that have been reported as yellow or straw colored. She has not had any thoracic or abdominal surgeries. We performed a diagnostic thoracentesis to rule out infection, as she had no ascitic fluid noted on ultrasound examination. The fluid appeared milky yellow and thick (Fig2). A pigtail catheter was then placed for drainage with concern for empyema (Fig3). Pleural fluid studies revealed a transudative fluid with 60 white cells and negative gram stain and culture. The triglyceride level was 149 mg/dl and cholesterol was 16 mg/dl. Ratio of Pleural fluid to serum triglyceride was 1.2 confirming chylothorax. Subcutaneous octreotide was started to reduce the portal hypertension and potentially reduce splanchnic lymphatic pressures. Patient was not a candidate for TIPS due to hepatic encephalopathy and high bilirubin. CT chest did not show lymphadenopathy or lung parenchymal abnormality. The chest tube was removed after a few days once the drainage slowed. DISCUSSION: Chylothorax is defined as pleural fluid triglyceride level >110mg/dl and cholesterol <200mg/dl, with the ratio of pleural fluid to serum triglyceride more than 1. Pseudochylothorax develops due to long-standing exudative effusions and will have pleural fluid cholesterol levels >200mg/dl. Chylothorax occurs most commonly due to malignant obstruction of the thoracic duct and only 1% of cases due to cirrhosis. The mechanism in cirrhosis is thought to be portal hypertension resulting in high pressures in the splanchnic lymphatic vessels. This causes rupture of lymphatics and leakage of chylous fluid in the peritoneal space. Chylothorax is usually exudative but is transudative in the setting of cirrhosis, nephrotic syndrome and heart failure. Chylous ascites is managed conservatively with a low-fat diet that contains more medium chain triglycerides. Total parenteral nutrition is an alternative in resistant cases. TIPS is an effective treatment in patients who don’t improve with conservative measures. CONCLUSIONS: Isolated chylothorax without chylous ascites has not been previously reported in literature, as was seen in our patient. Low fat diet and measures to reduce portal hypertension can be attempted to resolve the chylothorax. Reference #1: Romero S, Martín C, Hernandez L, et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest. 1998;114(1):154-9. Reference #2: Valdes L, Alvarez D, Pose A, Valle JM. Cirrhosis of the liver, an exceptional cause of chylothorax: two cases. Respir Med. 1996;90(1):61-2. Reference #3: McGrath EE, Blades Z, Anderson PB. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med. 2010; 104 (1): 1-8. DISCLOSURES: No relevant relationships by Sabin Bista, source=Web Response No relevant relationships by Deepak Chandra, source=Web Response No relevant relationships by Navin Victor, source=Web Response