Review Article

A Contemporary Review of Chylothorax

Arunabh Talwar1 and Hans J. Lee1
Department of Medicine, Division of Pulmonary and Critical Care Medicine, North Shore University Hospital1,
Manhasset, New York and Department of Medicine, NYU School of Medicine1, New York, USA

ABSTRACT
Objectives. This review will focus on anatomical and aetiologic factors as well as the conservative and operative therapy
of chylothorax.
Data Source. A Pubmed search for studies pertaining to the aetiology and/or treatment published in the English language
from 1960 to 2007.
Study Selection. Studies presenting case reports, series, observational and/or retrospective studies, and those with unique
issues pertaining to chylothorax were reviewed independantly by both authors. Studies that were selected by both authors
contain most clinically relevant data.
Results. Chylothorax is caused by injury or obstruction of the thoracic duct or its main tributaries leading to chyle
accumulation in the pleural space. It most commonly occurs from trauma or malignancy, but other causes have been
described. Although chylous effusions are rare, they have serious clinical consequences including cachexia and
immunodeficnecy. There are no evidence-based guidelines to assist in the management of this disease.
Conclusions. A prompt diagnosis is needed to start treatment of the underlying cause. Treatment can be divided into
conservative and surgical interventions. There are no evidence-based guidelines to assist in the management of this disease.
Initial conservative therapy includes intercostal decompression of the pleural effusion along with nutritional support in the
form of total parenteral nutrition, and reduction of chylous formation with somatostatin. Surgical interventions include thoracic duct ligation, pleuroperitoneal shunt and percutaneous embolisation. [Indian J Chest Dis Allied Sci 2008; 50: 343-351]
Key words: Chyle, Thorax, Pleural effusion, Injury, Lymph, Treatment

INTRODUCTION
Chyle in the pleural space was first described by
Bartolet in 1633 and since its initial description,
numerous causes have been well described. 1 The
pleural fluid in chylothorax consists of chylomicrons
and very low-density lipoproteins. It results from an
anatomical disruption of the thoracic duct and/or a
major lymphatic contributary. It was not until 1948 that
Lampson 2 reported the first successful treatment of
chylothorax by supradiaphragmatic ligation of the
thoracic duct. Although cylothorax accounts for a small
proportion of clinical pleural effusions, prompt
recognition is needed to avoid malnutrition, immunodeficency, and fibrothorax. Management requires the
physician to individualise the work-up, partly because
of diversity in the pathogenesis and anatomy.

ANATOMY
Chyle passes from the intestinal lymphatics to

cisterna chyli and then through the thoracic duct to

eventually empty into the venous system. The thoracic
duct begins at the cisterna chyli near the T-12 vertebra
and ascends through the aortic hiatus of the
diaphragm on the anterior surface of the vertebral
body between the aorta and the azygos vein into the
posterior mediastinum. At the level of the fifth thoracic vertebra, it then crosses to the left of the vertebral
column and ascends behind the aortic arch to the left
of the subclavian artery adjacent to the mediastinal
pleura. At the level of the transverse process of the
seventh cervical vertebra, the duct turns laterally and
runs anterior to the vertebral and thyrocervical
arteries and the sympathetic trunk. Passing behind
the carotid sheath, it descends anterior to the origin of
the left subclavian artery and terminates near the
junction of internal jugular and subclavian veins. A
bicuspid valve at the lymphovenous junction prevents the reflux of blood into the duct. The duct itself
has numerous valves throughout its length. However,
in up to 50% of individuals, the route of thoracic duct
is anomalous and unpredictable, thus making it
more susceptible to damage during surgical

[Received: August 14, 2007; accepted: November 15, 2007]

Correspondence and reprint requests: Dr Arunabh Talwar, Department of Medicine, Division of Pulmonary and Critical
Care Medicine, North Shore University Hospital, Manhasset, NY 11030, USA; Phone: 516-465-5400; Fax: 516-465-5454; E-mail:
arunabh@nshs.edu

Chylothorax

344

procedures.3 This duct carries lymph from the entire

body, except from the right side of the head, neck,
chest, both lungs, and the right upper extremity that
empties into the right lymphatic duct. There are
extensive anastomotic vessels present between
various lymphatics, and numerous lymphaticovenous anastomoses between the thoracic duct and the
azygos, intercostals, and lumbar veins.4 The richness
of this collateral circulation allows the safe ligation of
the thoracic duct at any level.

PHYSIOLOGY
The word chyle comes from the Latin word
meaning juice and is applied to the lymph of
intestinal origin. Ingested fats are transported by
chyle into the venous blood via the thoracic duct. In
the fasting state, chyle is usually clear, owing to a low
fat content. Both the protein content and the volume
are also diminished. After ingestion of a fatty meal,
chyle assumes its characteristic milky appearance.
It is estimated that up to 60% of ingested fat passes
into the lymphatics.
Between 1,500 to 2,500 milliliters of chyle is
normally emptied into the venous system daily. The
protein content of chyle is more than 3 gm/dL, and
the electrolyte composition of chyle is similar to that
of serum.5 Significant losses of chyle may result in
severe
nutritional
depletion,
especially
hypoproteinemia. The chyle formed in the cisterna
chyli is an odourless, white, opaque liquid. Analysis
of chyle reveals approximately 90% lymphocytes and
a white cell count of 2,000 to 10,000 cells per cubic
millimeter, which generally renders this fluid
bacteriostatic. It is believed that most of the
lymphocytes in chyle are T-lymphocytes. 6 Chemical
analysis reveals protein and fat globules that stain
with Sudan III dye. Chyle is also alkaline with a
specific gravity of greater than 1.012 and will settle on
standing with a fat-rich portion on the top and a
cellular sediment on the bottom. Chyle is noted to be
high in neutral fats and fatty acids, but low in
cholesterol. Flow through the thoracic duct can vary
widely from as low as 14 mL/h in the fasting state to
over 100 mL/h postprandial. Thoracic duct flow is
related to response of the duct wall smooth muscle to
splanchnic and vagal stimulation. Serotonin,
norepinephrine, histamine, dopamine, and
acetylcholine all increase thoracic duct contraction
and chyle flow. 7 In addition to starvation, intestinal
rest and administration of opiates will decrease the
volume of chyle.

PATHOGENESIS
The pathogenesis of chylothorax can be divided into
two major categoriessurgical and medical causes
(Table). Chylothorax from medical causes results from
either extrinsic compression or infiltration of the

A. Talwar and H.J. Lee

thoracic duct, that causes an increase in intraductal

pressure. This increased pressure promotes the
formation of dilated collateral channels that eventually drain into the pleural space. The most common
cause of chylothorax is neoplasm, which is
responsible for more than 50% of cases. The most
common malignancy leading to this condition is lymphoma,8 which leads to chylothorax by compressing
or invading the thoracic duct or obliterating the
lymphatics after radiation therapy.9 Obstruction of
the thoracic duct by lymphoma or bronchogenic
carcinoma tends to cause a right-sided chylothorax
when the lower portion of the duct is involved,
whereas a left-sided chylothorax results when the
upper portion of the thoracic duct is involved.
Chylothorax in the setting of malignancy below the
diaphragm invariably indicates metastasis. 10
The other leading cause of chylothorax are surgery
and trauma. Although any penetrating injury that
disrupts the thoracic duct would produce chylothorax, even severe coughing and straining have
reportedly caused this condition. 11 Surgical
procedures on the heart, mediastinum, operations in
the neck, such as radical neck dissections, and
placement of catheters in the superior vena cava for
hemodynamic monitoring may result in chylothorax.
Chylothorax is the most common cause of pleural
effusion in neonates, and it usually appears
spontaneously. 1,12-16 Systemic conditions, such as
Behcets amyloidosis, sarcoidosis,19 heart failure, and
nephritic syndrome, 20 comprise another group of
miscellaneous
conditions
associated
with
chylothorax.
Jaffe-Campanacci syndrome, which includes
disseminated non-ossifying fibromata has also been
reported to be associated with chylothorax. 21
Gorhams syndrome is a rare disease associated with
progressive osteolysis along with intraosseous
angiomatosis of lymphatics and blood vessels. Up to
17% of patients develop chylothorax as a
complication in this disease. 22 Pulmonary
lymphangioleomyomatosis is characterised by proliferation of immature smooth muscle throughout the
peribronchial, perivascular, and perilymphatic
region. It occurs primarily in women of reproductive
age and the perilymphatic proliferation of smooth
muscle results in lymphatic obstruction and
chylothorax in up to 50% of the patients. 23 This
condition may at times be present as a part of the
syndrome of pulmonary tuberous sclerosis.
A chylothorax may develop acutely without an
underlying cause and is referred to as spontaneous
chylothorax.24,25 Idiopathic chylothorax is uncommon
and comprises cases where no underlying cause can
be found. A sudden increase in duct pressure from
coughing, especially after a heavy meal when the
duct is engorged, may be a contributory factor. 26, 27
Despite detailed work-up the cause of chylothorax
may not be established in some instances.
Most of the cases of chylothorax are unilateral, but
bilateral chylothorax has also been reported, 25, 26, 28-32

2008; Vol. 50

The Indian Journal of Chest Diseases & Allied Sciences

for example, Kaposis sarcoma 33 has been reported to

result in bilateral chylothorax. Chylothorax and
chyloperitoneum have also been reported in patients
with nephritic syndrome, 19 malignancies such as
Wilms tumour 34, gall-bladder carcinoma,35 uterine
cancer,36 stomach cancer,10 lymphoma,37 retroperitoneal
surgery, 38 hypothyroidism, 39 sarcoidosis 18, yellow
nail syndrome, 40 idiopathic, 41 primary lymphatic
lymphangiomyomatosis, 42
and
dysplasia, 15
43
pancreatitis.

CLINICAL FEATURES AND DIAGNOSIS

The usual presenting symptom is dyspnoea due to
accumulation of pleural fluid. Chest pain and fever
are uncommon because chyle is not irritating to the
pleural surface. Traumatic chylothorax usually
develops within two to ten days post injury.5 In nontraumatic chylothorax, the onset of symptoms is more
insidious. Spontaneous chylothorax may rarely
present as a sudden neck mass. 24,31 The severity of
symptoms is related to the rate of accumulation of
chyle and the size of the pleural effusion.
The more serious sequelae of chylothorax are
malnutrition, weakness, dehydration, metabolic
acidosis, and compromised immunologic status due
to the loss of chyle, which is rich in proteins, fats,
electrolytes, bicarbonate, lymphocytes, and fatsoluble vitamins. Prolonged chylothorax may be
associated with reversible T-cell deficiency.44 Hypoalbuminemia and lymphopenia secondary to
prolonged loss of chyle increase the risk of systemic
bacterial and viral infections. There is a good
correlation between rate of chyle loss, operative
intervention, and survlval.45
Chyle is often suspected only after a thoracentesis.
Chyle is distinctively white, odourless, and milky in
appearance. The diagnosis of chylothorax is established by measuring triglyceride levels in the pleural
fluid. If triglycerides are greater than 110 mg/dL, the
diagnosis is probably chylothorax; conversely, if the
level is less than 50 mg/dL, chylothorax is unlikely.
When levels are between 50 to 110 mg/dL,
lipoprotein analysis should be performed.
Chylomicrons in the fluid establish the diagnosis of
chylothorax.46 Milky or creamy pleural fluid can also
be
associated
with
a
condition
called
pseudochylothorax. 5 In this condition, usually
associated with chronic diseases, such as
tuberculosis, turbidity is the result of high levels of
cholesterol or lecithin-globulin complexes and not
chylomicrons. The effusion is usually of longstanding duration and may cause thickened and even
calcified pleura. The presence of cholesterol crystals
in the fluid is diagnostic of pseudochylothorax, and
chylomicrons are never present on lipoprotein
analysis. Both chylous and pseudochylous fluid
remain opaque after centrifugation, but the turbidity
of chylous fluid clears out on addition of two
millilitres of ethyl ether. Thus, whenever there is any

345

doubt, the fluid should be analysed for chylomicrons.

Another useful test is the ingestion of lipophilic
dye or radio-labeled triglyceride ( 131 I-triolein).
Presence of the dye colour in the fluid within one
hour or detection of high radioactivity in the pleural
fluid after 48 hours confirms the presence of
chylothorax. 5 Lymphangiography may be helpful in
defining the site of chyle leak or obstruction or
penetrating trauma in spontaneous chylothorax and
in lymphangiomatous malformations. 47 Lymphangiography has also demonstrated a therapeutic
role in assisting occlusion of the post-operatively
damaged lymphatic vessel. This may occur from an
inflammatory granulomatous reaction by the lipiodol
dye during extravasation. 48

MANAGEMENT
Initial management is determining the aetiology.
Surgical causes are more obvious. As lymphoma is
the most common cause of chylothorax in the nonsurgical setting, a computed tomography (CT) of the
chest and abdomen should be performed to evaluate
mediastinal and para-aortic lymph nodes. Primary
treatment must be directed at the underlying cause. In
most instances surgical therapy should be pursued
only after failure of conservative therapy. However,
the timing of surgical management does not have
consensus.

Conservative Therapy [Figure 1]

The initial approach to management of chylothorax
involves chest tube drainage of the pleural space.49-51
Continuous suction drainage helps to relieve the
pressure of chyle on the lungs, re-expands the
partially collapsed lungs, obliterates the pleural
space, and permits an accurate measurement of chyle
production. Lung re-expansion is sometimes hindered by formation of a fibrinous membrane around
the lung, which may necessitate surgical
intervention. 52 The rate of chyle leakage can be
actually measured and recorded, if the chest tube is in
place. Chest tube drainage of less than 500 mL during
the first 24 hours aftar complete oral intake cessation
and total parenteral nutrition may predict successful
conservative treatment.53
Because up to three liters of chyle may drain daily,
large amounts of fluid, electrolytes, fat, protein, and
lymphocytes may be lost leading to severe nutritional
depletion and an immunodeficiency state. Careful
monitoring of chyle output and replacement of daily
losses are essential, as is monitoring of the patients
weight, serum albumin, total protein, absolute
lymphocyte count, and electrolyte levels. A non-fat,
high-protein, high-calorie diet will produce some
reduction of chyle flow. Administration of mediumchain triglycerides (MCTs) as a source of fat is invaluable.54 The MCTs are absorbed directly into the portal
system rather than the intestinal and thoracic

Chylothorax

346

A. Talwar and H.J. Lee

Chylothorax

Conservative Management

Treat Underlying Cause

Chylothorax Resolves within

Two Weeks

Remove Chest Tube

Monitor for Recurrence

Effusion > 1L/day

Nutritional Deterioration

Chest Tube Drainage

Dietary Changes (MCT, TPN, NPO)
Somatostatin

Surgical Management

Figure 1. Conservative treatment and management of chylothorax.

lymphatics. With the use of MCTs, not only is the

nutrition satisfactorily maintained, but thoracic duct
flow is minimised to promote healing of the leak. It
has been suggested that in the selection of MCTs,
trioctanoin (C8:O) may be the preferable MCT
substrate for these patients.55 The MCT diets have met
with variable success in the treatment of chylothorax.
This is because: (i) any oral enteral feeding increases
lymph flow, 56 and (ii) intestinal triglycerides are
derived from both endogenous and exogenous
sources.57 If drainage remains unchanged, parenteral
alimentation should be started. Others have
recommended stopping oral feeding and initiating
total parenteral nutrition (TPN) at the time of diagnosis. 5 Comparison of enteral versus parenteral
nutrition in the setting of chylothorax shows that the
thoracic duct closure occurs faster with TPN.58
If there is imminent nutritional deterioration,
surgical intervention is indicated. If a patient is on
mechanical ventilation, adding a positive endexpiratory pressure would lead to an increase in
intrathoracic pressure, help approximate the two
intrapleural surface and potentially decrease chyle
leakage. 59 Thomson and Simms 60 have reported
successful reinfusion of chyle drained from the chest
tube using blood filters and a volumetric pump, but

anaphylactic reactions have been reported after

intravenous transfusion of chyle.61 Somatostatin is an
inhibitor of gastric, pancreatic, and intestinal secretions, thereby helping to keep the gastrointestinal tract
empty, which in turn decreases the chyle
production. 62
Octreotide is an analog of somatostatin and has
been used in conjunction with other modalities (i.e.,
TPN, effusion drainage) in conservative management
of various aetiologies of chylothorax.63-65 Because of
octreotides longer half-life, it offers a subcutaneous as
well as intravenous route of administration. The
support for octreotide is limited to case reports and
small series, making the therapeutic effectiveness of
octreotide difficult to differentiate from spontaneous
improvement or other concurrent treatments. Due to
the lack of existing evidence, we cannot recommend
octreotide as a first-line agent at this time.
Treatment of the underlying cause may be helpful,
especially in patients where chylothorax is secondary
to lymphoma, where radiotherapy to the mediastinum is given to resolve the tumour mass.
Mediastinal tumours associated with chylothorax,
such as lymphangiomas, also respond to
radiotherapy. 66
The duration of the conservative management is

2008; Vol. 50

The Indian Journal of Chest Diseases & Allied Sciences

not firmly established and must be related to

pathogenesis, underlying comorbid illness, and
institutional experience. Operative intervention in
chylothorax should be considered when: (i) average
daily loss has exceeded 1,500 milliliters per year of
age in children for a five-day period;52 (ii) chyle flow
has not diminished over 14 days; (iii) nutritional
complications appear imminent; or (iv) accumulation
of chyle is continuous despite chest tube drainage.
Chylothorax associated with sarcoidosis will
respond very well if the patient is treated with
steroids. Patients with Gorhams syndrome and
chylothorax
should
be
treated
with
a
pleuroperitoneal shunt or thoracic duct ligation. 22
Pulmonary lymphangiomyomatosis can be treated
with hormonal manipulation targeting high-affinity,
low-capacity progestin-binding sites. 67, 68 In a metaanalysis of 30 cases of lymphangioleiomyomatosis
treated with various hormonal manipulations, it was
concluded that the administration of progesterone,
oophorectomy, or both results in improvement or
stabilisation of the disease. 69 Lung transplantation
may be the ultimate answer to this problem.70

Surgical Therapy [Figure 2]

Two weeks is often used as the limit for resolution by

conservative management, 45,52 but there are no large

controlled studies to confirm this recommendation. It
is appreciated that patients draining more than 1,000
millilitres per day may benefit from earlier (5-7 days)
surgical intervention 74 because of a higher mortality
with increased output.
Failure of conservative treatment in cases of
surgical chylothorax requires a surgical intervention
for definitive management. Lampson 2 first
demonstrated that chylothorax could be controlled by
ligation of the thoracic duct. Pre-operative
administration of lipophilic dye (e.g., Evans blue or
cream) helps to locate the site of lymphatic leakage
during the procedure. The thoracic duct is then
identified, isolated, and ligated just above the aortic
hiatus between T-8 and T-12.72 After ligation, there is
usually some obstruction to lymph flow distal to the
ligated site until new collateral channels are formed
(2 to 3 weeks).73 An abdominal approach to ligate the
thoracic duct is an alternative in patients where
thoracic approach is not feasible. 74 Others have
described a posterior extra-pleural approach to
ligation of the thoracic duct. 75 Most recently, videoassisted thoracic surgery has provided an effective
and potentially less invasive approach to
chylothorax.

Conservative Management
Failure

Treat Underlying Causes

Surgical Management

Lymphatic Imaging Study

Consider Percutaneous
Embolisation or
Pleuroperitoneal Shunt or
Pleurodesis

Percutaneous Embolisation

Chylothorax Resolves

Chylothorax Resolves

Thoracic Duct Ligation

347

Consider Thoracic Duct

Ligation or
Pleuroperitoneal Shunt or
Pleurodesis

Figure 2. Surgical treatment and management of chylothorax

348

Chylothorax

Successful ligation of the thoracic duct by

thoracoscopy using fibrin glue or endoscopic clips at
the site of leak has been attempted,76-78 and has the
advantages of less post-operative pain and a shorter
hospital stay. Graham and colleagues 79 have
described successful use of video-assisted thoracic
surgery in 10 patients of chylothorax and recommend
early operative intervention with this procedure.
Early thoracoscopic repair has two major advantages:
(i) the risk of malnutrition is minimised; and (ii) postthoracotomy pain and discomfort are avoided. In
situations where it is impossible to identify the duct
surgically, especially in malignancy and radiation
fibrosis, pleurodesis or pleurectomy may be used. 80
These procedures have not only been used alone but
also in combination with thoracotomy and ligation of

the thoracic duct. Talc pleurodesis is most often used

in chylothorax due to malignant disease that is
resistant to conservative treatment. Other approaches
include intrapleural infusion of tetracycline, 81 fibrin
glue, 82 and OK-432, 83 a Substrain of streptococcus
pyogenes. Intra-pleural bleomycin has been found to
be more effective in patients with chylothorax
secondary to lymphoma.84
The surgical approach to nontraumatic chylous
effusions is more variable. Milsom and co-workers85
recommend pleuroperitoneal shunting after failure of
conservative therapy and before thoracotomy.
Murphy and associates1 have recommended placing
the shunt if the drainage persists beyond five days. A
pleuro-peritoneal shunt consists of pleural and
peritoneal catheters connected to a manual pumping

Table. Causes of chylothorax

Surgical

Medical Causes

Post-operative

Neoplasms

Thoracoscopic procedures
Thymectomy (32)
Coronary artery bypass (95)
Congenital heart disease (96)
Bochdalek herniography (97)
Esopageal resection (98)
Sclerotherapy for varices (99)
Celiac plexus block (100)
Radical neck dissection (101)
High translumbar aortography (102)
SVC or subclavian catherisation (29, 103)
Amputation of upper arm (104)
Gastric resection (105)
Pulmonary resection (106)
Non-surgical Trauma
Penetrating gunshot or stab wound (5)
Blast or crush injuries (5)
Weight lifting or straining (5)
Severe bout of coughing or vomiting (5)
Vigorous stretching while yawning (11)

Number in parantheses indicate study reference number;

A. Talwar and H.J. Lee

Lymphoma (8)
Gastric carcinoma (10)
Chronic lymphocytic leukemia (118)
Bronchogenic carcinoma (107)
Gall-bladder carcinoma (35)
Multiple myeloma (108)
Wilms tumour (34)
Prostate carcinoma (109, 110)
Uterine cancer (36)
Pulmonary Kaposis (111)
Mediastinal lymphagiomas (66)
Infections
Filariasis (1)
Bilharziasis (1)
Tuberculosis (1,112)
Miscellaneous
Behcets syndrome (17)
Amyloidosis (18)
Sarcoidosis (19)
Cirohosis (1)
Heart failure (1)
Tuberous sclerosis (1)
Nephrotic syndrome (20)
Gorhams syndrome (22)
Post-irradiation (9)
Pregnancy (113)
Retrosternal goiter (114)
Hypothyroidism (39)
Yellow nail syndrome (40)
Lymphangiomyomatosis (42)
Intestinal lymphatic dysplasia (115)
Primary lymphatic dysplasia (15)
Congenital pulmonary lymphangiectasia (16)
Jaff-Campanacci syndrome (21)
Sclerosing mediastinitis (116)
Hypobetalipoproteinemia (117)
Pancreatitis (43)
Spontaneous (26)*
Downs syndrome (12)*
Noonans syndrome (13)*
Turners syndrome (1)*
Maternal polyhydraminos (1)*
*Associated with neonatal chylothorax

2008; Vol. 50

The Indian Journal of Chest Diseases & Allied Sciences

chamber capable of handling viscous fluid such as

chyle. The system contains a one-way valve that
allows drainage from pleura to the peritoneal cavity
where the fluid is absorbed. Shunting seems to
prevent further loss of chyle and its nutritionally
important constituents, 86 potentially reducing the
need for TPN.87 The fluid present in the peritoneal
cavity is absorbed by the lymphatic vessels, mainly
those of the diaphragm on the right side overlying the
liver, which in turn drain into the right thoracic duct.
Occlusion of the shunt with fibrinous debris occurs in
about 10% of patients and requires replacement. 88
Obviously, concomitant presence of ascites is a
contraindication to pleuroperitoneal shunt
placement and a pleurovenous shunt may be
considered in these cases.89
An alternative to surgical ligation of thoracic duct
may be fluoroscopic percutaneous embolisation. This
minimally invasive proceaure requires pedal
lymphography to access the lymphatic duct via transabdominal puncture. 90-92 Once access is obtained a
small catheter (3-4F) using contrast dye opacifies the
thoracic duct and collateral branches. The use of
various coils and/or glue can occlude the thoracic
duct. Limitations of this procedure are difficulties in
access to lymphatic duct and pedal lymphography.
The success rate is variable, ranging from 45 percent
to 100 percent. 91,92 Percutaneous embolisation offers a
minimally invasive procedure with low morbidity
and can be safely preformed at an earlier time
compared to surgery even in debilitated patients.92-94

CONCLUSIONS

6.

7.

8.
9.
10.
11.
12.

13.
14.

15.

16.

17.
18.
19.

20.
21.

There are numerous causes for chylothorax. The

aetiology should be ascertained because treatment will
be tailored to the underlying pathogenesis. Other
considerations include nutritional status, severity of the
underlying disease, and, proper delineation of the
thoracic duct anatomy in planning treatment. When
conservative management fails, appropriate surgical
intervention or percutaneous embolisation must be
considered.

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