Nyatsambo Chido, Moeng Maeyane Steve, Ngwisanyi Weludo
Division of Acute Care Surgery, Department of Surgery, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Soweto, South Africa.
Division of Trauma, Department of General Surgery, Charlotte Maxeke Johannesburg Academic Hospital, 5 Jubilee Street, Parktown, Johannesburg, South Africa.
Int J Surg Case Rep. 2023 Sep;110:108637. doi: 10.1016/j.ijscr.2023.108637. Epub 2023 Aug 6.
Chylothorax is a rare condition secondary to a chyle leak from the thoracic duct. The most common cause is after thoracic and cardiac surgery. Other causes include malignancy, non-iatrogenic trauma, and miscellaneous disorder - tuberculosis, filariasis and idiopathic conditions. The incidence of chylothorax post non-iatrogenic trauma is low; however, it does occur. Therefore, clinicians managing trauma patients should be aware of chylothorax as a differential and understand how it can be managed.
Our patient presented in respiratory distress 5 days after sustaining a stab to the chest. His chest X-ray showed a massive left pleural effusion with mediastinal shift. An Intercostal drain (ICD) was inserted and, drained 2 l of a white milky fluid - confirmed to be chyle on biochemistry. Other potential differentials like empyema and a pseudochylothorax, were excluded. He was kept nil-per os, received total parenteral nutrition and the ICD output was monitored. Subsequently the drainage decreased and eventually cleared, and the ICD was removed on day 8 of admission. Chest X-rays showed resolution of the effusion, and the patient was discharged.
Patients with trauma can present with chylothorax after penetrating or blunt trauma. The diagnosis can be made by checking the fluid triglyceride level or the presence of chylomicrons. Once the diagnosis is confirmed, the clinician should decide on either conservative or surgical. Due to the condition's rarity, there are no randomized control trials comparing different treatment modalities.
Despite the patient's delayed presentation, he was successfully managed conservatively.
乳糜胸是一种因胸导管乳糜漏引起的罕见病症。最常见的病因是胸科和心脏手术后。其他病因包括恶性肿瘤、非医源性创伤以及其他杂症——结核病、丝虫病和特发性病症。非医源性创伤后乳糜胸的发病率较低；然而，确实会发生。因此，治疗创伤患者的临床医生应知晓乳糜胸这一鉴别诊断，并了解其治疗方法。
我们的患者在胸部被刺伤5天后出现呼吸窘迫。他的胸部X光显示左侧大量胸腔积液伴纵隔移位。插入了肋间引流管（ICD），引出了2升白色乳状液体——生化检查证实为乳糜。排除了其他可能的鉴别诊断，如脓胸和假性乳糜胸。患者禁食，接受全胃肠外营养，并监测ICD的引流量。随后引流量减少并最终清除，入院第8天拔除了ICD。胸部X光显示积液消退，患者出院。
创伤患者在穿透性或钝性创伤后可能出现乳糜胸。通过检查液体甘油三酯水平或乳糜微粒的存在可做出诊断。一旦确诊，临床医生应决定采用保守治疗还是手术治疗。由于该病症罕见，尚无比较不同治疗方式的随机对照试验。
尽管患者就诊延迟，但通过保守治疗成功治愈。
