Medical College of Georgia York, PA, United States
Award: Presidential Poster Award
Ayesha Cheema, MBBS1, Hafiz Muhammad Sharjeel Arshad, MD1, Asad Jehangir, MD2, Loc Ton, MD3, John Erikson Yap, MD4 1Medical College of Georgia, York, PA; 2Medical College of Georgia, Augusta, GA; 3Kaiser Permanente Sacramento, Sacramento, CA; 4Medical College of Georgia at Augusta University, Augusta, GA
Introduction: Isolated chylothorax (in the absence of chylous ascites) due to cirrhosis is very rare condition. Only 1 case has been reported in literature. We present a case of isolated chylothorax caused by cirrhosis which was successfully treated by trans-jugular intrahepatic portosystemic shunt (TIPS)
Case Description/Methods: A 54-years-old female with past medical history of hypertension, diabetes mellitus and obesity was referred to the gastroenterology clinic with a new diagnosis of cirrhosis. Patient was found to have nodular appearing liver during an aborted bariatric surgery and intraoperative biopsies confirmed cirrhosis. Patient subsequently developed peripheral edema and was started on furosemide 40mg and spironolactone 100mg. After a few months, patient developed severe dyspnea and presented to the emergency room. A chest X-ray and CAT scan of chest without contrast showed large right pleural effusion and near-complete atelectasis of right lung (Figure 1a and 1b). Thoracentesis performed by interventional pulmonology showed 3 liters of cloudy yellow milky thick fluid (Figure 1d). Fluid analysis confirmed transudative fluid (fluid protein < 3 g/dl, fluid LDH 50 U/L). Pleural fluid triglycerides were 225 mg/dl and the fluid cholesterol was < 25 mg/dl. These results were consistent with chylothorax. Fluid cultures and cytology results were negative for malignancy or infection. Abdominal ultrasound did not show ascites. Although patient was started on medium chain triglyceride diet, she had 3 further recurrences of large pleural effusions requiring weekly large volume ( >1L) therapeutic thoracentesis. Outpatient CAT scan of abdomen and pelvis showed recurrent right pleural effusion and cirrhosis without significant ascites and portal vein thrombosis (Figure 1c). Patient was also referred for liver transplant evaluation. After multidisciplinary discussion, TIPS was placed for treatment of recurrent chylothorax. Patient’s portosystemic pressure gradient reduced from 25 mmHg to 9 mmHg after TIPS placement. No further recurrence of pleural effusion was observed on 6 months outpatient follow-up.
Discussion: Portal hypertension causing high splanchnic lymphatic pressure resulting in rupture of lymphatics is thought to be the underlying mechanism of chylothorax in cirrhosis. Isolated chylothorax is very rare complication of cirrhosis. If medium chain triglycerides fail to resolve symptoms, TIPS should be considered for management of recurrent isolated chylothorax.
Figure: Figure 1. Panel 1a. Chest X-ray showing large right sided pleural effusion. Panel 1b. CAT scan of chest showing right sided pleural effusion and atelectasis. Panel 1c. CAT scan of abdomen showing pleural effusion and nodular appearing liver. Panel 1d. Thoracentesis showing cloudy yellow pleural fluid.
Ayesha Cheema indicated no relevant financial relationships.
Hafiz Muhammad Sharjeel Arshad indicated no relevant financial relationships.
Asad Jehangir indicated no relevant financial relationships.
Loc Ton indicated no relevant financial relationships.
John Erikson Yap indicated no relevant financial relationships.
Ayesha Cheema, MBBS1, Hafiz Muhammad Sharjeel Arshad, MD1, Asad Jehangir, MD2, Loc Ton, MD3, John Erikson Yap, MD4. P1845 - Transjugular Intrahepatic Portosystemic Shunt for Treatment of Recurrent Isolated Chylothorax Caused by Cirrhosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.