Hemothorax and chylothorax
Types Hemothorax Chylothorax
Definition Accumulation of blood in pleural space Accumulation of thoracic duct lymph (chyle) in pleural
space
Etiology 1. Trauma 1. Traumatic
- Blunt / penetrating - Blunt: Spinal hyperextension
- Source : - Penetrating:
o IC vessels o Above T5: left chylothorax
o Internal thoracic vessels o Below T5: right chylothorax
o Bronchial arteries 2. Operative
o Great vessels Surgery of aortic arch, subclavian artery,
o Heart esophagus
2. Iatrogenic 3. Congenital
- Post operative - Birth trauma
- Thoracocentesis - Thoracic duct abnormalities
- Needle biopsy 4. Neoplastic
3. Spontaneous - Obstruction (lymphoma) causes rupture
- Tear of vascular adhesions - Invaded by lung/eso cancer
4. Effusion - Benign tumors
- Neoplasm 5. Infections
- Pulmonary embolism TB lymphadenitis
- TB 6. Miscellaneous
- Spontaneous: violent cough causes shearing at
right diaphragmatic crus
- Idiopathic
Clinical Post operative Non operative
picture Milky chest tube Dyspnea
drainage after start Physical evidence
oral intake Radiological evidence
Ix 1. History: Trauma
2. Physical signs: Thoracocentesis + Gram stain WBC:
- Pleural fluid signs pleural fluid Bac: 0
- Pallor analysis Sudan III stain Fat globules
3. CXR Fat content > plasma
Pleural collection Lipid analysis: Cholesterol/
4. Thoracocentesis is diagnostic triglyceride
ratio: 1500 ml blood
# massive
# clamp the tube to tamponade
bleeding
# immediate thoracotomy
o >1000 ml + hypotension
- Tube drainage >300ml/h for 3 hours
- Drainage inadequate (persistent)
Manage : associated intrathoracic injuries
Evacuate: clotted hemothorax
[after 4-6 weeks clot organization requires
decortications] - [Direct ligation at site of leak is < effective]
Other procedure:
- Anastomosis of thoracic duct to azygous vein
- Fibrin glue
- Radiotherapy
- Pleurodesis with talc