Abstract Introduction Chylothorax is an uncommon cause of pleural effusions characterized by pleural fluid triglyceride levels 110 mg/dl. The differential is broad, with the most common causes being thoracic surgery and lymphoma. We present a case of non-traumatic chylothorax secondary to cirrhosis. Case A 42-year-old male with a history of alcoholic cirrhosis with prior transjugular intrahepatic portosystemic shunt (TIPS) procedure presented to the hospital with dyspnea. Computed tomography revealed a pulmonary embolism complicated by pleural effusion. He underwent thoracentesis, and therapeutic enoxaparin was intiatiated. Fluids studies at the time were consistent with a transudative effusion with a triglyceride level 110 mg/dl. The effusion was attributed to hepatic hydrothorax and did not recur. At clinic follow-up, the patient’s pleural effusion had not recurred.Seven months later, he was readmitted with similar pleural fluid characteristics, and his effusion was again attributed to hepatic hydrothorax. He was admitted with a similar presentation four months later with similar pleural fluid characteristics and was diagnosed with chylothorax. He was treated with a low-fat diet without recurrence. Two months later, he was admitted with a similar presentation. A chest tube was placed inpatient, and he was treated with octreotide and dietary modifications with eventual resolution. His chest tube was removed, and he underwent dietary counseling prior to discharge. Despite a low-fat diet, monitoring, and serial thoracentesis, he required admission and lymphangiogram. Thoracic duct embolization was unsuccessful; however, he was able to undergo inguinal node embolization. He was discharged home with plans for follow-up. Discussion Cirrhosis often leads to portal hypertension, which can result in excessive lymph flow. Very rarely this leads to disruption of the thoracic duct and chylothorax. This is often successfully relieved with a TIPS procedure. Chylothorax is almost always exudative except in the case of cirrhosis where it is often associated with a transudative effusion. This case presents several unique challenges. The patient had already undergone TIPS prior to his initial presentation, and his fluid studies were consistent with a transudate leading to the diagnosis of recurrent hepatic hydrothorax. This case highlights the importance of early recognition of cirrhosis as a rare but well-described cause of chylothorax even in those who have undergone TIPS and have a transudative effusion. Our patient’s case was further complicated by long stretches of improvement followed by recurrent effusion. Ongoing clinic follow up is scheduled. If this effusion recurs, the patient will undergo definitive management with chemical pleurodesis. This abstract is funded by: None
Frederickson et al. (Fri,) studied this question.