Chylothorax and Chyloperitoneum

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     A 76-year-old man underwent elective repair of an abdominal aortic aneurysm, and in the subsequent eight weeks, exertional dyspnea, orthopnea, and abdominal pain developed. On physical examination, the patient was afebrile, and his vital signs were normal. There was a dull percussion note and decreased breath sounds over the right lower lung field. The abdomen was protuberant and diffusely tender. The serum triglyceride level was 1.21 mmol per liter (normal, <1.70 mmol per liter). A chest radiograph demonstrated a right pleural effusion (Panel A). Computed tomography of the abdomen revealed gross ascites containing particulate matter but no other abnormalities. Subsequent thoracentesis and paracentesis yielded a milky fluid (Panel B). Cytologic examination of the fluid by means of staining with oil red O showed lipid deposits within phagocytic cells (Panel C), leading to a diagnosis of chylothorax and chyloperitoneum. The pleural effusion and ascites resolved with drainage, adherence to a low-fat diet, and supplementation with medium-chain triglycerides (which directly enter the portal system rather than the intestinal lymphatics). The patient continues to do well at 18 months. It is presumed that the integrity of the thoracic duct was compromised during an otherwise uncomplicated repair of the aortic aneurysm.

    Thai Yen Ly, M.D.

    Robert A. Fowler, M.D.

    University of Toronto

    Toronto, ON MN4 3M5, Canada

    http://www.100md.com/html/DirDu/2007/01/01/32/58/47.htm