Chylothorax: Medical and Surgical Management

Michael B. Mison, DVM, Diplomate ACVS 

Seattle Veterinary Specialists

Chylothorax is a collection of chyle in the pleural space.  Chylothorax remains a complicated condition that is poorly
understood and difficult to treat.  In most animals, abnormal flow pressures within the thoracic duct are thought to
lead to exudation of chyle from intact, but dilated, thoracic lymphatic vessels.  Increased lymphatic flow, decreased
lymphatic drainage, or both may lead to dilation of the thoracic lymphatic vessels and subsequent exudation of chyle. 
Possible causes of chylothorax include anterior mediastinal masses (mediastinal lymphosarcoma, thymoma), heart
disease (cardiomyopathy, heartworm disease, congenital cardiac diseases, etc.), fungal granulomas, congenital
abnormalities of the thoracic duct, and diffuse lymphatic abnormalities.  Trauma is an uncommonly recognized cause
of chylothorax in dogs and cats since the thoracic duct heals rapidly following injury and within a few weeks the
effusion resolves without treatment.  Despite extensive diagnostic workups, in the majority of the animals, the
underlying etiology is undetermined (idiopathic chylothorax).

Any breed dog or cat may be affected.  A breed predisposition has been suspected in the Afghan hound and Shiba
Inu.  Among cats, Oriental breeds such as Siamese and Himalayan appear to have an increased prevalence. 
Coughing is often the first abnormality noted by owners until the animal becomes dyspneic.  Other clinical signs are
signs consistent with animals with pleural effusion.  These include dyspnea and muffled lung and heart sounds. 
Chylothorax is diagnosed on the basis of aspirating milky-appearing fluid form the pleural space, which contains
chylomicrons, as determined on the basis of microscopic examination, and has a cholesterol:triglyceride ratio of <1:1
or triglyceride concentration that is higher than the serum triglyceride concentration.  The physical characteristics of
the fluid is consistent with a modified transudate.  The total nucleated cell count is usually less than 10,000 and
consists primarily of small lymphocytes or neutrophils.  The protein content is variable and may be inaccurate due to
interference of the refractive index by the high lipid content of the fluid.   

Diagnostic evaluation of dogs and cats with chylothorax, using radiography, ultrasonography, fluid analysis,
echocardiography, and other tests, is intended to rule out primary diseases that may cause effusion.  If the animal is
not overtly dyspneic, thoracic radiographs should be taken to confirm the diagnosis of pleural fluid.  Delay thoracic
radiographs until after thoracocentesis in animals with pleural effusion that are severely dyspneic.  Radiographic
signs associated with pleural effusion include undefined cardiac silhouette, interlobar fissure lines, rounding of lung
margins, and separation of lung borders from the thoracic wall.  If the animal is stable and ultrasonography is
available, ultrasonography should be performed fluid removal because the fluid acts as an acoustic window
enhancing visualization of thoracic structures.  Ultrasonography is used to evaluate cardiac function, valvular lesions
and function, congenital cardiac abnormalities, the presence of pericardial effusion, pleural effusion, and mediastinal
masses.   

If an underlying disease is diagnosed it should be treated and the chylous effusion managed by intermittent
thoracocentesis.  However, in a large percentage of animals, a primary cause is not identified.  Many treatments have
been recommended for animals with idiopathic chylothorax.  Non-surgical methods include pleural drainage, dietary
management and vitamin supplementation, and pharmaceutical control.  Palliative drainage of the thorax is important
for alleviating signs of respiratory distress.  However, chest drainage alone only allows for temporary resolution of
effusion.  Chyle contains many beneficial substances such as protein, electrolytes, and fat-soluble vitamins.  Long-
term drainage of chyle from the thorax may lead to dehydration, hypoproteinemia, malnutrition, electrolyte
disturbances, and possible immune deficiency.  Long term medical management of chylothorax may lead to chronic
inflammation causing restrictive pleuritis that can be a serious, life-threatening sequelae of chronic chylothorax. 
Dietary management includes the use of a low-fat diet to decrease flow through the thoracic duct, which in turn
reduces the volume of effusion.  However, studies have shown that the use of low fat-diet reduces the lipid content of
the effusion but  does not seem to effectively decrease the volume of effusion.  By decreasing the amount of fat in the
effusion, it may improve the animal’s ability to resorb fluid from the thoracic cavity.   Supplementation of oils high in
medium chain triglycerides (MCT) has been recommended but its benefit is uncertain.  MCT reportedly will bypass
intestinal lymphatic vessels and be absorbed directly into the portal system.  But current studies have shown that
MCT-containing oils is absorbed through intestinal lymphatic vessels and thus, may be of little benefit for animals with
chylothorax.  With regards to pharmaceutical control, benzopyrone drugs have been used for the treatment of
lymphedema in humans for years.  Reportedly, these drugs act by stimulating macrophages to break down proteins
in lymph which promotes reabsorption.  Whether there might be effective in decreasing pleural effusion in animals
with chylothorax is unknown and requires further study.

Surgical intervention is often attempted when medical treatment is not effective or when animals have severe
respiratory complications.  Surgical methods include thoracic duct ligation, pleuroperitoneal or pleurovenous shunts,
pleurodesis (not recommended), and omentalization of the thoracic cavity.  Thoracic duct ligation has long been used
as a treatment for dogs and cats with chylothorax.  This procedure is intended to stop flow of chyle into the pleural
space by diverting lymphatic flow to alternate lymphaticovenous pathways.  The thoracic duct is approached via a
right sided thoractomy in dogs and via left sided thoracotomy in cats.  The dust is usually ligated in the caudal aspect
of the mediastinum near the diaphragm.  An alternate method of occlusion of the thoracic duct  is via embolization. 
Isobutyl 2-cyanoacrylate can be injected through a catheter placed in a mesenteric lymphatic vessel which leads to
complete obstruction of the thoracic duct.  Results of studies have shown that thoracic duct ligation in successful in
20-60% of dogs and cats with chylothorax.  Recurrence is possible, therefore, results that initially appear favorable
should be viewed cautiously, especially for animals that have not yet had long-term follow-up monitoring. 
Pleuroperitoneal or pleurovenous shunts are devices that allow movement of fluid from the thoracic to abdominal
cavity where it can be absorbed by serosal surfaces and omentum, or to the venous circulatory system.  Active
shunts or drains are those that remove fluid from a cavity using negative pressure, as opposed to those relying on
gravity to provide passive drainage.  Potential complications include clotting of the tubing, sepsis, and adherence of
the liver or omentum to the implant.  Omentalization of the thoracic cavity uses the physiological properties of
omentum to control the pleural effusion.  The omentum has a large surface area with absorptive lymph-draining
capability and early case reports on transplanting the omentum into the thoracic cavity in small animals with
chylothorax have shown some promise but has only been used in a limited number of cases.  

Chylothorax remains a complicated condition that is poorly understood and difficult to treat.  Although results of
recent studies have improved our understanding of the pathophysiologic mechanism of the disease, treatment failure
remains common. Additional research is needed to better delineate the pathophysiologic mechanism of idiopathic
chylothorax and to improve treatment results.

References:
1.    Fossum TW, Birchard SJ, Jacobs RM:  Chylothorax in 34 dogs, J Am Vet Med Assoc 188:1315, 1986
2.    Fossum TW et al:  Chylothorax in cats:  37 cases (1969-1989), J Am Vet Med Assoc 198:672, 1991
3.    Birchard SJ, Smeak DD, Fossum TW:  Results of thoracic duct ligation in dogs with chylothorax, J Am Vet Med
Assoc 193:68, 1988
4.    Hodges CC, Fossum TW, Evering W.  Evaluation of thoracic duct healing after experimental laceration and
transection.  Vet Surg 1993;23:431-435
5.    Birchard SJ, Fossum TW.  Chylothorax in the dog and cat.  Vet Clin North Am Small Anim Pract 1987; 17:271-
283
6.    Pardo AD, Bright RM, Walker MA, et al. Transcatheter thoracic duct embolization in the dog.  An experimental
study.  Vet Surg 1989; 18:279-285
7.    Birchard SJ, Smeak DD, McLoughlin MA:  Clinical Update: Treatment of idiopathic chylothorax in dogs and cats. 
J Am Vet Med Assoc 212:5, 1998
8.    Thompson MS, Cohn LA, Jordan RC:  Use of rutin for medical management of idiopathic chylothorax in four
cats.  J Am Vet Med Assoc. 1999 Aug 1;215(3):345-8, 339.
9.    Williams JM, Niles JD:  Use of omentum as a physiologic drain for treatment of chylothorax in a dog.  Vet Surg
28:61-65, 1999
10.    Fossum TW Ed.  Small Animal Surgery. St. Louis, Missouri:  Mosby-Year Book, Inc.  1997:691-698

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Results of thoracic duct ligation in dogs with chylothorax.

Birchard SJ, Smeak DD, Fossum TW.

Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus 43210.

Abstract
Thoracic duct lymphangiography and ligation were done on 15 dogs with idiopathic chylothorax. Lymphangiography
revealed thoracic lymphangiectasia in all dogs; none had a thoracic duct rupture. Lymphangiography immediately
after ligation demonstrated missed branches of the thoracic duct in 4 of the 15 dogs. Eleven of the 15 dogs are alive
and doing well. Eight of the 11 had no radiographic or clinical signs of pleural effusion (mean follow-up, 31.5 months;
range, 4 to 75 months). The other 3 living dogs had persistent effusion; 2 were successfully managed with a
pleuroperitoneal shunt (follow-up, 15 months) or pleurodesis (follow-up, 5 months), respectively, and 1 was not
treated because the effusion was mild and the dog did not have clinical signs of disease (follow-up, 14 months). Four
of the 15 dogs died or were euthanatized because of persistent effusion (mean follow-up, 11.5 months; range, 3 to 24
months). Considering the lack of treatment alternatives for dogs with idiopathic chylothorax, these results support
thoracic duct ligation as a treatment method for dogs.

PMID: 3417529 [PubMed - indexed for MEDLINE]

Chylothorax in the dog and cat: a review.

Birchard SJ, McLoughlin MA, Smeak DD.

Department of Veterinary Clinical Sciences, Ohio State University, Columbus, USA.

Abstract
Chylothorax is a rare but complex disorder in domestic animals. Etiologies include neoplasia, fungal infections,
heartworm infestation, cardiac disease, thrombosis of the cranial vena cava, and congenital anomaly of the thoracic
duct. Most cases of chylothorax in dogs and cats are idiopathic. Positive contrast lymphangiography on dogs and
cats with chylothorax consistently reveals extensive lymphangiectasia of mediastinal and pleural lymphatics.
Reported treatment modalities for chylothorax in animals include removal of the etiologic agent, such as a mediastinal
tumor, thoracic duct ligation, and implantation of active or passive drainage devices such as a pleuroperitoneal shunt.
Thoracic duct ligation has been most successful in our experience, but continued study is needed since treatment
failures are common.

PMID: 7564493 [PubMed - indexed for MEDLINE]

[En bloc ligation of the thoracic duct in twelve dogs with idiopathic chylothorax]
[Article in Dutch]

Viehoff FW, Stokhof AA.

Hoofdafdeling Geneeskunde van Gezelschapsdieren, Faculteit der Diergeneeskunde, Universiteit Utrecht, Postbus 80154,
3508 TD Utrecht.

Abstract
Twelve dogs with idiopathic chylothorax were treated by en bloc ligation of the thoracic duct. Six dogs recovered
completely. Minimal follow-up in this group was 12 months. Five dogs were euthanized within 5 months of surgery
because of persisting liquothorax: two with chylous and three with non-chylous effusions. One dog was euthanized 2
months after surgery because of a recurrence of dyspnoea. It is concluded that the results are comparable with those
of a previously described surgical treatment; however, the technique described here is less complicated because it
does not require mesenteric lymphangiography.

PMID: 12769037 [PubMed - indexed for MEDLINE]

Evaluation of mesenteric lymphangiography and thoracic duct ligation in cats

with chylothorax: 19 cases (1987-1992).
Kerpsack SJ, McLoughlin MA, Birchard SJ, Smeak DD, Biller DS.

Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio State University, Columbus 43210.

Abstract
Mesenteric lymphangiography and thoracic duct ligation were performed on 19 cats with chylothorax between 1987 to
1992. Chylothorax was diagnosed on the basis of detection of chylomicrons in the pleural effusion or determination of
a cholesterol concentration:triglyceride concentration ratio of < 1 in the pleural fluid. Preoperative medical treatment
consisted of thoracentesis (19 of 19 cats) and feeding a fat-restricted diet (14 of 19 cats). Positive-contrast
mesenteric lymphangiography was performed before thoracic duct ligation to identify an underlying cause for the
effusion. Lymphangiectasia was diagnosed by use of radiography in 17 cats, none of which had evidence of a
thoracic duct rupture. Thoracic duct ligation was performed via an incision made through the left 10th intercostal
space. Lymphangiography was repeated immediately after ligation of the thoracic duct to document occlusion of all
branches. Follow-up monitoring was done for 12 to 47 months (median, 28 months) and consisted of physical
examination, evaluation for clinical signs related to pleural effusion, and thoracic radiography. Ten of 19 (53%) cats
had complete resolution of pleural effusion. Nonchylous effusion, localized in the right hemithorax, was detected in 1
cat 2 months after thoracic duct ligation, but resolved after thoracotomy, breakdown of thoracic adhesions, and
expansion of the right cranial lung lobe. Chylous effusion resolved 3 to 7 days (mean, 5.4 days) after surgery in the
10 cats that survived > 12 months after surgery. Four cats died between 2 and 13 days after thoracic duct ligation,
but pleural effusion had resolved in 3 of these 4 cats at the time of death.(ABSTRACT TRUNCATED AT 250
WORDS)

PMID: 7989240 [PubMed - indexed for MEDLINE]

Vet Rec. 2008 Dec 20-27;163(25):743-5.

Treatment of idiopathic chylothorax in 14 dogs by ligation of the thoracic duct

and partial pericardiectomy.
Carobbi B, White RA, Romanelli G.

Dick White Referrals, London Road, Six Mile Bottom, Newmarket, Suffolk CB8 0UH, UK.

Abstract
The outcome and complications associated with thoracic duct ligation combined with partial pericardiectomy in 14
dogs with idiopathic chylothorax were investigated retrospectively. Nine of the dogs were treated in the uk and five in
Italy. All of them were reassessed clinically four weeks after surgery and the respiratory function and any pleural fluid
accumulation were evaluated; they were followed up by telephone contact for at least six months. Eleven of the dogs
were clinically normal and had no radiographic signs of pleural effusion when reassessed after four weeks. Two
showed radiographic signs of a minor accumulation of pleural fluid but were clinically normal; when reassessed after
three months they showed similar radiographic signs and clinical findings; but after four months there was no
evidence of pleural effusion. One dog had a major complication that required a second surgical intervention.

PMID: 19103616 [PubMed - indexed for MEDLINE]

Subcutaneous accumulation of chyle after thoracic duct ligation in a dog.

Farnsworth R, Birchard S.

Department of Veterinary Clinical Sciences, Ohio State University, Columbus 43210, USA.

Abstract
A 3.5-year-old female German Shepherd Dog developed subcutaneous accumulation of chyle in a hind limb after
ligation of the thoracic duct for treatment of chylothorax. Lymphangiography revealed severe lymphangiectasia in the
abdomen and left inguinal region. Although the pleural effusion resolved, the subcutaneous accumulation of chyle
continued even after medical and surgical treatment, which included transplantation of the greater omentum into the
subcutaneous tissues of the affected limb. Alternate lymphaticovenous pathways usually develop in dogs after
thoracic duct ligation. These apparently did not develop in this dog, resulting in retrograde flow of chylous fluid into
the hind limb. To the authors' knowledge, this is a previously unrecognized complication of thoracic duct ligation for
treatment of chylothorax in dogs.

PMID: 8707676 [PubMed - indexed for MEDLINE]

Chylothorax in Dogs and Cats

Jennifer L. Rockwell, DVM; Perry J. Bain, DVM, PhD; Halise L. Diamond, DVM; Kenneth S. Latimer, DVM,
PhD

Class of 2003 (Rockwell), Department of Pathology (Bain, Latimer), and Department of Anatomy and
Radiology (Diamond), College of Veterinary Medicine, The University of Georgia, Athens, GA 30602-7388

Introduction

Chylothorax develops when chyle, fluid containing a high concentration of chylomicrons and lymph, effuses
from the thoracic duct-cisterna chyli system into the pleural space. 1,6 Chylothorax is fairly uncommon in
dogs and cats, is usually secondary to other conditions or diseases, and can be difficult to treat. 2 Chylous
effusion classically has been described as a milky-white pleural fluid that fails to become clear upon
centrifugation. Pseudochylous effusion is also milky white, resembles chylous effusion grossly, and typically
is associated with chronic inflammatory thoracic disease. Pseudochylous effusions do not contain chylomicra,
clear upon centrifugation, and contain cholesterol and protein-lecithin compounds, giving them a higher
cholesterol content than serum.1
 Figure 1. Typical milky appearance of chylous Figure 2. Chylous effusion may have a pink
effusion. tinge due to erythrocytes in the effusion.

Figure 3. Necropsy photograph of a cat with chylothorax. Notice

the milky white effusion fluid surrounding the heart and lungs.

Pathophysiology
Dietary lipids, including triglycerides, cholesterol and phospholipids, undergo four major processes of
assimilation. The first stage, emulsification, breaks up the lipids into smaller droplets. Emulsification starts in
the stomach and continues into the small intestine. Stomach activity breaks the lipid globules into smaller
droplets which can pass easily into the duodenum. Once the lipids are in the small intestine, bile acids coat
and decrease the surface tension of lipid droplets, which further reduces the size of the emulsified droplets.
The second stage, hydrolysis, occurs in the jejunum. Pancreatic enzymes such as lipase, co-lipase,
cholesterol esterase and phospholipase degrade lipids in the emulsified droplets into nonesterified fatty
acids, monoglycerides, cholesterol and lysophospholipids. In the third stage, micelle formation, the products
of hydrolysis combine with bile acids and phospholipids to form micelles, which are water-soluble. The fourth
stage is absorption, during which the micelles diffuse across the apical membranes of enterocytes in the
jejunum. The bile acids do not enter the enterocyte, but are reabsorbed in the ileum. Once inside the
enterocytes, the lipids are re-esterified into triglycerides and phospholipids. The re-esterified lipids then
combine with cholesterol, other lipids and proteins to form chylomicrons. Chylomicrons are small, water-
soluble structures with a core of hydrophobic, nonpolar lipids and an outer coat of polar lipids. The
chylomicrons are then absorbed into intestinal lymphatics, which travel to the cisterna chyli. The thoracic
duct carries the chylomicrons from the cisterna chyli into the venous circulation for distribution to tissues. 8

Chylous effusions may result from leakage of chyle from intact lymph vessels or thoracic duct perforation.
Obstruction of lymphatic flow commonly causes lymphatic hypertension, dilation of lymphatics, and
subsequent leakage of lymph.1Chylothorax may be idiopathic in dogs and cats, but several causes have been
implicated including cardiomyopathy, thoracic and mediastinal neoplasia, mediastinal fungal granulomas,
heartworm disease, congenital lymphatic defects, trauma, chronic vomiting or coughing, lymphangiectasia
or rupture of lymphatic vessels, diaphragmatic hernia, lung lobe torsion, and venous thrombi. 1,3,4,9 Rupture
of the thoracic duct secondary to trauma was once thought to be the sole cause of chylothorax, but it has
been shown that the thoracic duct remains intact in the majority of patients. 1,5

Table 1. Differential diagnoses for chylothorax in dogs.

 Congenital abnormalities of the thoracic duct

 Diaphragmatic hernia
 Fungal infections
 Heartworm disease
 Idiopathic
 Lung lobe torsion
 Lymphangiectasia
 Neoplasia
 Trauma and rupture of thoracic duct
 Venous thrombi

Table 2. Differential diagnoses for chylothorax in cats.

 Cardiomyopathy
 Heartworm disease
 Idiopathic
 Lymphangiectasia
 Mediastinal neoplasia (lymphoma, thymoma)
 Trauma and rupture of the thoracic duct

Clinical Presentation and Diagnosis

There does not seem to be a gender predisposition for the development of chylous effusion in cats or dogs.
Age does seem to be a factor, as trauma-related, idiopathic, and congenital causes of chylothorax tend to
occur in younger dogs. Chylothorax associated with neoplasia and heart disease tend to occur in older
animals.3,4 A breed predisposition seems to exist in dogs and cats, with purebred cats, Afghan Hounds, and
Mastiffs having an increased relative risk for development of chylothorax. 3,4

Diagnosis is made based on physical examination, clinical signs, thoracic radiographs, and pleural fluid
analysis. The most common presenting signs in both dogs and cats are dyspnea and coughing. Other clinical
signs and historical findings include weight loss, anorexia, gagging, lethargy, gagging, regurgitation,
vomiting, exercise intolerance, and salivation. Abnormal physical findings most commonly include dyspnea,
muffled heart sounds, increased bronchovesicular sounds, and tachycardia. 3,4 Thoracic radiographs should be
performed, depending on the clinical status of the animal, but thoracocentesis may be necessary to stabilize
the animal. Supplemental oxygen and dorsoventral radiographs may be required depending on the degree of
dyspnea. Radiographs typically reveal pleural effusion (Figs. 4 & 5), which may be unilateral or
bilateral.5 Ultrasonography and echocardiography may be useful in identifying an underlying cause of the
effusion, such as cardiomyopathy or mediastinal neoplasia.

Figure 4. Lateral thoracic radiograph illustrating pleural Figure 5. Ventrodorsal thoracic radiograph
effusion. The lungs and heart are displaced dorsally by the of a dog with chylothorax illustrating pleural
effusion fluid. effusion.

The complete blood count may reveal mature neutrophilia due to inflammation and lymphopenia from the
loss of lymphocytes into the fluid.4 The serum chemistry profile may disclose hypoalbuminemia,
hyponatremia, or hyperkalemia. Hypoalbuminemia results from protein deficiency and frequent removal of
effusion. Hyponatremia may result from removing fluid containing electrolytes (therapeutic drainage of the
chylous effusion). Hyperkalemia may be due to hypovolemia and/or renal secretion defects of potassium. 1

Pleural fluid analysis is required for the diagnosis of chylothorax. Grossly, chylous effusion is milky white or
pink, depending on the degree of hemorrhage associated with the effusion (Figs. 1 & 2). Chylous effusions
should not clot or have an odor, and should be free of particulate matter. 1 Collecting the fluid into an EDTA
tube allows for cell counts on the sample.5 A culture and sensitivity should be performed, although chyle is
considered to be bacteriostatic.1,4 Initial microbial cultures on 32 cats in one study and 23 dogs in another
study were negative for bacterial; however, secondary infections were reported after repeat thoracocentesis
or surgery in 5 cats and 6 dogs.3,4 The effusion should form a cream layer upon standing in the tube because
chylomicra have a low density and rise to the surface.
Upon centrifugation, the sample should become white following centrifugation if red blood cells are present
(although the presence of hemolyzed erythrocytes will result in a fluid that remains red or pink following
centrifugation), and should remain opaque.1

Cytologic and Chemical Characteristics

Laboratory analyses that may be performed on the fluid include determination of specific gravity, total
protein concentration, total and differential cell counts, cholesterol and triglyceride concentrations, and ratio
of cholesterol to triglyceride. In two studies of cats with chylothorax, effusion fluid had a mean specific
gravity of 1.030 and 1.032, and mean total protein concentration of 5.0 and 5.32 g/dl. 4,5

The mean white blood cell count of the effusion fluid was 11,919 cells/µl in one feline study, and 6,167
cells/µl in one canine study.3,4 Typically, a predominance of small lymphocytes is considered characteristic of
chylous effusion; however, increase in neutrophils and macrophages may be associated with chronicity. 1 The
increase in neutrophils may occur as a result of an irritant effect of the effusion on the pleural lining or due
to repeated therapeutic drainage of the effusion with subsequent peripheral lymphopenia. In a study of 19
dogs with chylothorax, neutrophils were the predominant cell type in most effusion specimens; however,
macrophages predominated in 4 dogs while lymphocytes were most common in only 2 dogs. 3 Differential
nucleated cell counts performed on effusion fluid of cats with chylothorax indicated that lymphocytes were
the predominant cell in 19 of 26 specimens. The remaining 7 specimens had a predominance of segmented
neutrophils.4

Figure 6. Cytology of classical chylothorax with many Figure 7. Cytology of chronic chylothorax containing
small lymphocytes. (100X, Wright’s stain). a mixture of small lymphocytes, neutrophils, and
macrophages. (100X, Wright’s stain)

 
 Figure 8. Cytology of effusion fluid from a cat with lymphosarcoma
and chylous effusion. Note the presence of lymphoblasts, small
lymphocytes, and neutrophils. (100X, Wright’s stain)

Comparison of concurrent serum and pleural fluid cholesterol and triglyceride concentrations and cholesterol
to triglyceride ratios of the effusion can be helpful in diagnosing chylous effusion and differentiating chylous
from pseudochylous effusion. Chylous effusions are typically characterized by cholesterol concentrations that
are decreased or within the reference interval and an elevated triglyceride concentration as compared to
serum. In contrast, pseudochylous effusions usually have elevated cholesterol concentrations, while
triglyceride concentrations are equal to or lower than those of serum. Triglyceride concentrations may be
increased markedly in chylous effusion, as chylomicrons are composed largely of triglyceride. Cholesterol to
triglyceride ratios in chylous effusion are typically less than 1. Fluid to serum triglyceride ratios greater than
2-3:1 are diagnostic for chylous effusion; ratios of 10-20:1 are commonly encountered. 1

An ether clearance test is a quick test that may confirm the fluid is chylous. The ether clearance test is
performed as follows: Divide the effusion into two test tubes, and add two drops of 10% potassium
hydroxide to each tube. Dilute the first tube with a volume of water equal to the sample as a control, and
add an equal volume of ether to the second tube. Invert the tubes, and the chylomicrons in the sample
should dissolve in the ether. The first tube should appear diluted, but second tube should become
clear.5 This test is not routinely performed. Caution: Ether is hazardous and should be handled and
stored properly to prevent health and explosion hazards.

Treatment and Prognosis

Note: Treatment of animals should only be performed by a licensed veterinarian. Veterinarians

should consult the current literature and current pharmacological formularies before initiating any
treatment protocol.

Treatment of chylothorax is dependent on the cause of the effusion. Both medical and surgical therapy have
been used. An underlying cause or primary disease process should be identified and corrected, if possible.
Medical therapy consists of thoracocentesis, dietary management, and drug therapy. Thoracocentesis allows
palliative drainage and clinical improvement of respiratory distress. 2 Initial thoracocentesis may be
performed with a needle, but chest tube placement may be required for daily drainage. 5 Traditionally, it has
been suggested that the animal be placed on a low-fat diet to decrease the amount of lipid absorbed via
intestinal lymphatics; however, loss of fat-soluble vitamins, lipids, and protein-rich lymph fluid may
contribute to a state of malnourishment in the animal. It has been shown recently that a low-fat diet does
not decrease the flow volume of effusion. It was once thought that supplemental medium-chain triglycerides
would provide additional dietary lipid and bypass the thoracic duct because they were absorbed directly into
the portal circulation. However, it has been demonstrated recently that the medium-chain triglycerides do
not bypass the thoracic duct.1,5 In cases of severe malnutrition, parenteral nutrition can bypass the
gastrointestinal system and decrease lymphatic flow.2 Rutin (a benzopyrone compound extracted from the
fruit of the Brazilian Fava D’Anta tree) administration may result in clinical improvement of cats with
idiopathic chylothorax. Suggested mechanisms of action for rutin include reduced leakage of lymph from
lymphatic vessels, increased protein removal by lymphatics, increased phagocytosis by stimulation of
macrophages, increased recruitment of macrophages in tissues, and increased proteolysis and removal of
protein from tissues.7

Surgical management typically is performed in cases where medical therapy has failed. 5 Surgical options
include ligation of the thoracic duct, pleurodesis, and pleuroperitoneal or pleurovenous shunts. Ligation of
the thoracic duct has been shown to be beneficial in 20% to 60% of dogs and cats with idiopathic
chylothorax. Positive contrast mesenteric lymphangiography is useful to determine lymphatic anatomy and
post-ligation success. Chylous or nonchylous effusions may continue to accumulate after ligation of the
thoracic duct. Subcutaneous accumulation of chyle also has been reported in a dog after thoracic duct
ligation.10 Pleurodesis is the formation of adhesions between the parietal and visceral pleural surfaces.
Substances such as tetracycline and talc have been infused to create adhesions, but studies in veterinary
medicine reveal questionable efficacy. Pleuroperitoneal or pleurovenous shunts may be beneficial, but are
associated with complications such as infection, adhesions, and clogging of the implants. 2

Regardless of the cause, chylothorax has been associated with poor survival rates in dogs and cats. 3,4 A
common sequela to chylothorax is restrictive pleuritis, resulting in an inability to expand the lungs. 4 Chyle is
irritating to the pleural surface; chronic exposure to chyle may cause fibrin deposition and connective tissue
formation on the pleura resulting in restrictive pleuritis. 1,4 Although chylothorax is rare, it is usually a fatal
disorder in dogs and cats. Additional studies are needed to determine causes of idiopathic chylothorax and
develop viable treatment options.3,4,5

References

1. Meadows RL, MacWilliams PS: Chylous effusions revisited. Vet Clin Pathol 23:54-62, 1994.

2. Birchard SJ, Smeak DD, McLoughlin MA: Treatment of idiopathic chylothorax in dogs and cats. J Am Vet
Med Assoc212:652-657, 1998.

3. Fossum TW, Birchard SJ, Jacobs RM: Chylothorax in 34 dogs. J Am Vet Med Assoc 188:1315-1317, 1986.

4. Fossum TW, Forrester SD, Swenson CL, Miller MW, Cohen ND, Boothe HW, Birchard SJ: Chylothorax in
cats: 37 cases (1969-1989). J Am Vet Med Assoc 198:672-678, 1991.

5. Fossum TW: The characteristics and treatments of feline chylothorax. Comp on Cont Ed 914-928, Sept
1998.

6. Breznock EM: Management of chylothorax: Aggressive medical and surgical approach. Vet Med
Report 1:380,382-384.

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Titre du document / Document title

Thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax

Auteur(s) / Author(s)
FOSSUM Theresa W. ; MERTENS Michelle M. ; MILLER Matthew W. ; PEACOCK John
T. ; SAUNDERS Ashley ; GORDON Sonya ;PAHL Galen ; MAKARSKI Lori A. ; BAHR Anne ; HOBSON Phil H. ;

Résumé / Abstract
Chylothorax is a devastating disease, and the success rates from either medical or surgical management are less
than satisfactory. In some animals with chylothorax, a thickening of the pericardium occurs that is associated with
chronic irritation induced by chyle. We hypothesized that pericardial thickening would lead to increased right-
sided venous pressures and that abnormal venous pressures would act to impede the drainage of chyle via
lymphaticovenous communications after thoracic duct (TD) ligation. We also hypothesized that serosanguineous
effusions that occurred after TD ligation could effectively be treated or prevented by pericardectomy in affected
animals. TD ligation plus pericardectomy was performed in 17 animals, and pericardectomy alone was performed
in an additional 3 animals that presented during a 5.5-year period to the Texas A&M University (College Station,
TX). Nineteen animals presented for an evaluation of idiopathic chylothorax (9 dogs and 10 cats), and 1 dog
presented for serosanguineous pleural fluid after TD ligation that had been performed elsewhere.
Echocardiography was normal in all animals, except for a subjectively thickened pericardium in 7 cats and 6 dogs.
Clinical signs of pleural fluid accumulation resolved in 10 of 10 dogs and in 8 of 10 cats after surgery. The overall
success rate for the surgical treatment of chylothorax (ie, the resolution of pleural fluid accumulation) in this
study was 90% (100% in dogs and 80% in cats). These data suggest that TD ligation in coniunction with
nericardectomv has a favorable outcome in animals with idiopathic chylothorax.

Revue / Journal Title

Journal of veterinary internal medicine    ISSN  0891-6640 

Source / Source
2004, vol. 18, no3, pp. 307-310 [4 page(s) (article)]
Idiopathic chylothorax – unsolved problem in the
pleural cavity in a dog and a cat

Kirsi Juuti, Pauli Keränen and Jessica Eriksson

SUMMARY

Idiopathic chylothorax is the accumulation of chyle in the pleural cavity causing anorexia, coughing,
respiratory distress and exercise intolerance. Diagnosis is made by taking radiographs, blood samples
and an effusion sample. An effective medication has not been found. The goal of the treatment is to
decrease the accumulation of chyle and improve the resorption to the systemic circulation. It is
possible to obtain a fairly good result with a diet, rutin medication and surgery. Prognosis is still
guarded or poor.

This report describes the diagnostics and treatment of chylothorax in the dog and the cat along with a
typical canine patient developing chylothorax despite of surgery. No explanation to the symptoms was
found by postmortem examination.
 FIGURE 1

Hydrothorax in a feline patient. This chylothorax was caused by mediastinal neoplasia, (Cat Clinic
Felina, year 2000). Because of the increased fluid, it is not possible to see the structures in the
thoracic cavity.
 FIGURE 2

Lymphangiography before the ligation of ductus thoracicus in the dog of the case report. Ductus
thoracicus goes along the thoracic vertebrae after it has entered into the thoracic cavity from the
abdomen. No branching is visible.
 FIGURE 3

Ligation of the thoracic duct in the thoracic cavity in the dog of the case report.

FIGURE 4

Postoperative lymphangiography. Lymph flow to the thoracic cavity has stopped after the ligation
(arrow). Radiodense markerstripes of the gauze are visible.

THORACIC DUCT LIGATION

The thoracic duct is the largest lymph vessel and is present in the chest. In older times
it was thought that chylothorax resulted from a tear in the duct, spilling lymph into the
chest. This turns out generally not to be the case but ligation of the duct is successful
in permanently resolving chylothorax in 50% of dogs undergoing surgery. Less than
40% of cats achieved resolution. In patients where surgery was not successful, fluid
build up continued (though not always chyle, sometimes just watery fluid would
return).

PLEUROPERITONEAL SHUNTING
This technique involves placement of a sort of a drain in the diaphragm so that fluid
from the chest could drain into the belly where causes no harm. Shunts can be active
(where there is a pump that can be manually compressed) or passive where normal
breathing and motion moves the fluid. Complication rate is fairly high with this
procedure (nearly 50%) and it has not been recommended for cats. It does yield an
average of 20 months of symptom-free living in dogs.

THORACIC DUCT LIGATION WITH PERICARDECTOMY

This method appears to be the current treatment of choice. The pericardium is the
fibrous sac containing the he art. When it is bathed in chyle, it becomes thickened and
may be slightly constricting the low pressure right side of the heart. When the
pericardium is stripped away, lymph may be able to circulate in more normal channels
that it previously could not. When this procedure was combined with thoracid duct
ligation, chylothorax permanently resolved in 100% of dogs and 80% of cats. The
surgery is difficult and highly invasive (as one might imagine since it involves
manipulation of the heart) and should be performed by a surgery specialist only.