Chylothorax - Milliken Animal Clinic

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Chylothorax
Basics
OVERVIEW
• “Chylo-” refers to chyle; “thorax” refers to the chest
• “Chyle” is a milky to slightly yellow fluid composed of lymph
and fats (rich in triglycerides) taken up from the intestines and
eventually transferred to the circulation through the thoracic
duct; “lymph” is a watery fluid that contains white blood cells
that travels through lymphatic vessels—it transports
lymphocytes (a type of white blood cell) and fats from the small
intestines to the blood stream; the “thoracic duct” is the main
lymph vessel of the body—it crosses the chest near the spine,
and empties into the venous circulation
• “Chylothorax” is an accumulation of chyle in the space between
the chest wall and lungs (known as the “pleural space”)
• “Lymphangiectasia” is defined as the dilation of the lymphatic
vessels; it results from blockage or obstruction of the lymphatic
vessels
• Lymphangiectasia in the chest (known as “thoracic
lymphangiectasia”)—tortuous, dilated lymphatic vessels found in many pets with accumulation of chyle in the
space between the chest wall and lungs (chylothorax)
• Inflammation of the tissue lining the chest cavity and covering the lungs characterized by the development of
scar tissue (known as “fibrosing pleuritis”)—condition in which thickening of the tissue lining the chest cavity
and covering the lungs (known as the “pleura”) leads to constriction of the lung lobes; when severe, it results in
marked restriction of breathing; may be caused by any long-term (chronic) buildup of inflammatory fluid in the
space between the chest wall and lungs (known as “pleural exudate”), but is most commonly associated with
accumulation of chyle (chylothorax) or accumulation of pus (known as “pyothorax”)
GENETICS
• Unknown
SIGNALMENT/DESCRIPTION OF PET
Species
• Dogs
• Cats
Breed Predilections
• Dogs—Afghan hounds and Shiba Inus
• Cats—Oriental breeds (such as the Siamese and Himalayan)
Mean Age and Range
• Any age may be affected
• Afghan hounds—develop when middle-aged
• Shiba inus—develop when young (less than 1–2 years of age)
• Cats—more common in older cats than young cats; may indicate an association with cancer
Predominant Sex
• None identified
SIGNS/OBSERVED CHANGES IN THE PET
• Depend on the rate of fluid accumulation and volume of fluid in the space between the chest wall and lungs
(pleural space)
• Usually not exhibited until marked impairment of breathing
• Many pets appear to have condition for prolonged periods before diagnosis; they probably reabsorb the milky
fluid (chyle) at a rate that prevents obvious breathing impairment
• Rapid breathing (known as “tachypnea”)
• Difficulty breathing (known as “dyspnea”) or coughing; coughing may have been present for months before
examination
• Sluggishness (lethargy)
• Lack of appetite (known as “anorexia”) and weight loss
• Exercise intolerance
• Muffled heart and lung sounds detected when listening to the chest with a stethoscope (known as
“auscultation”)
• Increased lung sounds, particularly in the lung fields near the pet's back
• Pale gums and moist tissues of the body (known as “mucous membranes”)
• Bluish discoloration of the skin and moist tissues (mucous membranes) of the body caused by inadequate
oxygen levels in the red blood cells (known as “cyanosis”)
• Irregular heartbeats (known as “arrhythmias”)
• Heart murmur
• Detectable pulses in the jugular veins (known as “jugular pulses”), fluid buildup in the abdomen (known as
“ascites”), and enlarged liver (known as “hepatomegaly”) in association with right-sided heart failure
• Decrease in the ability to gently compress the front part of the chest—common in cats with a mass in the front of
the mediastinum; the “mediastinum” is the center portion of the chest that contains the heart and other organs
(except for the lungs)
CAUSES
• Unknown cause (so-called “idiopathic chylothorax”)—most common cause
• Masses in the front of the mediastinum (the center portion of the chest that contains the heart and other organs
[except for the lungs])—mediastinal lymphoma (lymphoma is a type of cancer that develops from lymphoid
tissue, including lymphocytes, a type of white blood cell formed in lymphatic tissues throughout the body);
thymoma (tumor that arises from the thymus)
• Heart disease—heartworm disease; disease of the heart muscle (known as “cardiomyopathy”); fluid buildup
between the heart and the sac surrounding the heart (known as “pericardial effusion”) or other pericardial
disease;
Twisting
of a lung lobe within the chest (known as a “lung lobe torsion”)
•
• Blood clots in veins
• Congenital (present at birth) abnormality of the thoracic duct (the main lymph vessel of the body)
• Heart or thoracic surgery
RISK FACTORS
• Unknown
Treatment
HEALTH CARE
• Pets with difficulty breathing (dyspnea) with suspected fluid buildup between the chest wall and lungs (pleural
effusion)—immediate medical procedure to tap the chest (known as “thoracocentesis”); removal of even small
amounts of pleural effusion can improve breathing markedly
• Identify and treat the underlying cause, if possible
• Medical management—usually treated on an outpatient basis, with intermittent procedures to tap the chest
(thoracocentesis), as necessary to prevent difficult breathing (dyspnea)
• Chest tubes—placed in pets with suspected chylothorax secondary to trauma (very rare), with rapid fluid
accumulation, or after surgery
• Surgery if medical management does not resolve the problem in 2–3 months
• Pets may become debilitated if procedures to tap the chest (thoracocentesis) are performed frequently; attention
to diet is important
• Chest taps (thoracocentesis)—perform under sterile conditions to reduce the risk of introducing infection into
the chest; antibiotics generally are unnecessary if sterile technique is used
• Pets undergoing multiple chest taps rarely can develop electrolyte abnormalities—if low levels of sodium in the
blood (known as “hyponatremia”) or high levels of potassium in the blood (known as “hyperkalemia”) are
present, fluid therapy will be necessary to normalize the electrolyte levels; electrolytes are chemical compounds
(such as sodium, potassium, and chloride) that are necessary for the body to function
ACTIVITY
• Pets usually will restrict their own exercise as the fluid volume in the space between the chest wall and lungs
increases or if they develop fibrosing pleuritis (inflammation of the tissue lining the chest cavity and covering
the lungs characterized by the development of scar tissue)
DIET
• Low-fat diet—may decrease the amount of fat in the fluid buildup in the space between the chest wall and lungs
(pleural effusion), which may improve thepet's ability to resorb fluid from the chest cavity; not a cure; may help
in management
• Medium-chain triglycerides—are transported via the thoracic duct in dogs, and are no longer recommended
SURGERY
Thoracic Duct Ligation and Surgical Removal of Part of the Sac Around the Heart (Known as
“Pericardiectomy”)
• Recommended in pets that do not respond to medical management
• The thoracic duct (the main lymph vessel of the body) usually has multiple branches in the back part of the
chest, where the surgical procedure to “tie off” or “ligate” the thoracic duct is performed; failure to ligate all
branches results in continued fluid buildup in the space between the chest wall and lungs (pleural effusion)
• Injection of methylene blue dye greatly facilitates visualization and complete ligation of all branches of the
thoracic duct
• Thickening of the sac around the heart (known as the “pericardium”)—perform surgical removal of part of the
sac around the heart (known as a “pericardiectomy”) simultaneously with tying off or ligation of the thoracic
duct
Other Surgical Considerations
• If thoracic duct ligation is not successful—may consider procedures in which the flow of lymph is shunted into
another part of the body
• Extensive fibrosing pleuritis (inflammation of the tissue lining the chest cavity and covering the lungs
characterized by the development of scar tissue)—makes surgery harder, but does not appear to affect prognosis,
if fluid buildup can be stopped
Medications
Medications presented in this section are intended to provide general information about possible treatment. The
treatment for a particular condition may evolve as medical advances are made; therefore, the medications should
not be considered as all inclusive
• Rutin, a bioflavonoid—complete resolution of fluid buildup (effusion) appears to occur in some pets; further
study is required to determine whether resolution occurs spontaneously or in response to this therapy
• Somatostatin (octreotide [Sandostatin®]), an inhibitory hormone—a naturally occurring substance that inhibits
secretions of the stomach, jejunum (middle section of the small intestines), pancreas and inhibits secretion of
bile by the liver; prolongs movement of food and fluids through the stomach and intestines (known as
“gastrointestinal transit time”), and stimulates water absorption in the intestines; resolution of fluid buildup
(pleural effusion) has occurred in dogs and cats with chylothorax of unknown cause (idiopathic chylothorax)
treated with octreotide
Therapy
to suppress the immune system (known as “immunosuppressive therapy”) may be of benefit in some
•
pets; cyclosporine is a medication that may be used
Follow-Up Care
PATIENT MONITORING
• Monitor closely for signs of recurrence of fluid buildup between the chest wall and lungs (pleural effusion), such
as rapid breathing (tachypnea), difficulty breathing (dyspnea), labored breathing, and respiratory distress;
perform procedures to tap the chest (thoracocentesis) as needed
• Resolution (spontaneously or following surgery)—periodically reevaluate for several years to detect recurrence
POSSIBLE COMPLICATIONS
• Fibrosing pleuritis (inflammation of the tissue lining the chest cavity and covering the lungs characterized by the
development of scar tissue)—most common serious complication of long-term (chronic) disease
• Introduction of infection (known as “iatrogenic infection”) with repeated chest taps (thoracocenteses)
• Decreased ability to develop a normal immune response (known as “immunosuppression”)—caused by
decreased number of lymphocytes; “lymphocytes” are a type of white blood cell that are formed in lymphatic
tissues throughout the body; lymphocytes are involved in the immune process—may develop in pets undergoing
repeated and frequent procedures to tap the chest (thoracocentesis)
EXPECTED COURSE AND PROGNOSIS
• May resolve spontaneously or after surgery
• Untreated or long-term (chronic) disease—may result in severe fibrosing pleuritis (inflammation of the tissue
lining the chest cavity and covering the lungs characterized by the development of scar tissue) and persistent
difficulty breathing (dyspnea)
• Euthanasia—frequently performed in pets that do not respond to medical management or surgery
Key Points
• No specific treatment will stop the fluid buildup (effusion) in all pets with chylothorax of unknown cause
(idiopathic chylothorax)
• The condition may resolve spontaneously in some pets after several weeks or months
Enter notes here
Blackwell's Five-Minute Veterinary Consult: Canine and Feline, Fifth Edition, Larry P. Tilley and Francis W.K. Smith, Jr. © 2011 John Wiley & Sons,
Inc.
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