Welcome back to the tasty morsels of critical care podcast.

Today we look at quite a niche topic, that of chylothorax. We are used to many things in the pleural space, like simple fluid or blood or air but the presence of the myseterious substance chyle is a much more unusual and note worthy event.

As a reminder of the basics which I of course knew implicitly and definitely did not have to resort to wikipedia to check…

Chyle is largely formed in the small intestine as the gut transports free fatty acids from the intestinal lumen. This combined with lymphatic flow is transported via the thoracic duct to the vasculature where it enters the circulation proper. The lipids in the chyle are transported in the form of wonderfully named chylomicrons.

The cisterna chyli is akin to the gall bladder of the lymphatic system, situated in the upper abdomen it drains a lot of the lymphatics from the gut before sending it on it’s jolly way through the diaphragm into the thoracic duct. Once in the thorax the thoracic duct has to run the gauntlet of the posterior mediastinum where it is frequently hunted and subjected to extreme violence by cardiothoracic or upper GI surgeons who are purportedly there for completely unrelated reasons. If the thoracic duct survives this odyssee then it drains into the sub clavian vein on the left.

As suggested, the commonest time we find chyle in the pleural space is when we notice the milky stuff in the drains that were left in place after said surgery. The other common context is apparently lymphoma or a number of other malignancies.

Chyle in the chest drain can be a yellowy milky thing or blood tinged. As a Deranged Physiology post quotes one group “to our surprise a quantity of fluid which resembled pale tomato soup was withdrawn”

To be definitive about the fluid you can measure triglycerides or even use electrophoresis to identify the above named chylomicrons.

Assuming we’re comfortable with the diagnosis, let’s turn to management. The duct is a fragile little beast, apparently too fragile for the surgeons to spot when they’re doing their original surgery and certainly not amenable to surgical repair. So like a lot of things in medicine it’s best to let the body sort it out itself and the body is best able to do this if we can reduce the flow through the duct.

Perhaps number one is the low fat diet, or at least providing fats in the form of medium chain fatty acids that can be absorbed through the portal vein bypassing the thoracic duct altogether. PN is naturally an option here. Our universal secretion dryer upper octreotide has also been used frequently and to effect.

This strategy appears effective in a certain somewhat undefined proportion cases. If it is not settling and still causing issues then our beloved friends in IR now have techniques allowing them to embolise the duct and our surgical colleagues, while not able to repair the duct can at least tie it off.

Reading

Deranged Physiology is excellently referenced, detailed and humorous in equal proportion

LITFL