Lymphangiography in Chylothorax

A 68-year-old man with alcoholic liver cirrhosis presented with right-sided pleural effusion.Chylothorax was diagnosed based on an elevated triglyceride concentration in the pleural fluid (252.5 mg/dL, compared to 37 mg/dL in the serum).The pleural effusion rapidly increased and required thoracic drainage.Neither a fat-restricted diet nor total parenteral nutrition reduced the effusion, and the patient continued to drain more than 1 L of fluid per day.Lymphangiography performed using the ethyl ester of iodinated poppy-seed oil fatty acid revealed non-visualization of the thoracic duct at the level of the diaphragm and no cephalad contrast migration (Picture A, B, C, and arrows).Ascites was minimal and unlikely to migrate into the thoracic cavity.Nonvisualization of the thoracic duct suggested the possibility of retrograde flow into the diaphragmatic lymphatics.Based on these findings, thoracic duct ligation or embolization was considered unlikely to be successful.Consequently, pleurodesis with minocycline was performed, leading to clinical improvement.This case indicates that preoperative lymphangiography can be valuable for determining the suitability of thoracic duct interventions in patients with chylothorax.