3 CE Credits

Idiopathic Chylothorax: Pathophysiology,

Diagnosis, and Thoracic Duct Imaging
Ameet Singh, DVM, DVSc, DACVS
Brigitte Brisson, DMV, DVSc, DACVS
Stephanie Nykamp, DVM, DACVR
University of Guelph
Guelph, Ontario
Canada

Abstract: Idiopathic chylothorax is a debilitating disease that can lead to respiratory and metabolic compromise and fibrosing pleuritis.
Previous investigation has provided theories for the etiology of this poorly understood disease. This article provides an overview of the
pathophysiology and diagnosis of chylothorax. Thoracic duct imaging, including minimally invasive techniques, is also discussed, as
it is frequently performed in the perioperative period. A companion article reviews nonsurgical and surgical techniques for treating and
managing idiopathic chylothorax in dogs and cats.

For more information, please see the companion article, “Idiopathic lymph to the vascular system by emptying into the venous system
Chylothorax in Dogs and Cats: Nonsurgical and Surgical Management” (lymphaticovenous anastomosis) at the level of the jugulocaval
angle3 (FIGURE 2). This maintains fluid balance and prevents tissue

C
hylothorax is a debilitating disease that occurs when disruption edema by returning interstitial fluid to the vascular system, thereby
of the thoracic duct (TD) results in chyle leakage into the acting as an adjunct to the cardiovascular system.
pleural space (FIGURE 1). Trauma to the TD during cardio-
thoracic surgery is the most common cause of chylothorax in
humans. While traumatic causes of chylothorax have been reported
in veterinary patients, most cases in dogs and cats are considered
idiopathic because a predisposing cause cannot be identified.1

The Lymphatic System

The human anatomist Gaspar Aselli is credited with the indirect
discovery of the lymphatic system in a dog in 1622.2 In his
experiments, he noted that “a great number of cords […] were spread
over the whole mesentery and intestine.”2 Aselli first believed these
white cords were nerves, but he realized this was not the case
when incising the largest cord yielded a “white milk- or creamlike
liquid.”2 This fluid was not seen after incision of a white cord in a
subsequent experimental dissection of a dog that had been fasted,
and Aselli linked digestion to the formation of the milky fluid.2
The lymphatic system has three primary roles: (1) maintain
fluid balance, (2) generate an immune response, and (3) perform
uptake and transport of dietary fats.3 Approximately 10% of fluid
extravasated into the interstitial space enters blind-ended lymphatic
capillaries and becomes lymph.3 These capillaries connect to Figure 1. Intraoperative image of a dog after right fifth intercostal thoracotomy.
larger lymphatic vessels that arborize into the TD. The TD, which The patient’s head is to the right, and the abdomen is to the left. Finochietto rib
is the largest lymphatic vessel in the body and located in the tissues retractors have been applied to improve visualization. Chyle is seen bathing the
heart and lungs within the pleural space.
dorsal to the aorta and ventral to the thoracic vertebrae, returns

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

Figure 2. Lateral thoracic radiograph after contrast lymphangiography in a normal Figure 4. Lateral thoracic radiograph after contrast lymphangiography in a dog
dog. The cisterna chyli (arrow) is highlighted in the cranial abdomen; its extension with idiopathic chylothorax. Dilated and tortuous cranial mediastinal lymphatic
is the thoracic duct (arrowheads). vessels (circle) are common in animals with idiopathic chylothorax.

The lymphatic system and mediastinal and pulmonary neoplasia.1 Cardiac diseases,
plays a key role in many including constrictive pericarditis, dirofilariasis, right ventricular
immune functions in the failure, double-chambered right ventricle, and tricuspid dysplasia,
body, including creating have also been reported as causes of chylothorax.5 However, in
immune cells and defending veterinary patients, a predisposing cause is rarely identified and
the body against infection chylothorax is most often deemed idiopathic.1 Idiopathic chylo-
and the spread of cancer. thorax is poorly understood.
The TD provides a conduit An experimental model of chylothorax developed by ligating
for immune cells as well as the cranial vena cava has been used to help determine the patho-
an entry point to the sys- physiology of idiopathic chylothorax.6 In dogs with experimentally
temic circulation.4 induced chylothorax, and in dogs and cats with naturally occurring
Dietary fats are absorbed idiopathic chylothorax, injection of contrast medium into a mes-
from small intestinal entero- enteric lymphatic vessel (mesenteric lymphangiography) reveals
cytes in the form of chylo- large, tortuous, dilated lymphatic vessels in the cranial mediastinum6
microns, which are large (FIGURE 4). These abnormal vessels in the cranial mediastinum
lipoprotein molecules (75 to are characteristic of lymphangiectasia. It has been theorized that
1200 nm).3 Chylomicrons lymphangiectasia of the TD, its tributaries, and/or the cranial
Figure 3. Characteristic “milky” appearance of predominantly consist of tri- mediastinal lymphatic vessels leads to transmural leakage of chyle
fluid retrieved from the pleural space of a dog
glycerides but also contain into the pleural space, causing chylothorax.6 Why the spontaneous
with chylothorax.
phospholipids, cholesterol, occurrence of a flow disturbance in the TD results in thoracic
and other proteins. After lymphangiectasia has not been determined and is the focus of
they are expelled from enterocytes, they are collected by villous ongoing research.
lacteals via exocytosis and eventually empty into the cisterna
chyli (CC). The CC is the abdominal lymphatic reservoir located Role of Venous Hypertension in Chylothorax
in the craniodorsal abdomen, and its cranial extension is the TD3 Several diseases that could elevate right-sided venous pressures,
(FIGURE 2). The “milky” appearance of intestinal lymph, or chyle, such as restrictive pericarditis, cranial vena caval thrombosis, and
is proportional to the concentration of chylomicrons3 (FIGURE 3). right ventricular failure, have been reported to cause chylothorax.
However, it has not been determined why all patients with elevated
Pathophysiology of Chylothorax right-sided venous pressures do not develop chylothorax (e.g., all
Numerous causes of chylothorax have been reported in the vet- cases of right ventricular failure do not lead to chylothorax). In two
erinary literature, all resulting in obstruction or impedance of TD independent studies, ligation of the TD at its entry into the venous
outflow at the lymphaticovenous anastomosis. They include fungal system at the level of the jugulocaval angle did not lead to chylo-
granuloma, trauma, cranial vena caval thrombosis, congenital thorax.6,7 This was thought to be a result of redirected lymphatic flow
abnormalities of the TD, diaphragmatic hernia, lung lobe torsion, through collateral channels that enter the cranial vena cava caudal

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

with chylothorax, respectively. Some patients exhibit respiratory

compromise when placed in lateral recumbency (orthopnea).
Thoracic percussion in a patient with pleural effusion produces a
dull, low, hyporesonant sound. Most patients with chylothorax
are normothermic.9,10
Chyle comprises proteins, dietary fats, electrolytes, fat-soluble
vitamins, and cells of the immune system. Chronic loss of chyle into
the pleural space can lead to metabolic compromise characterized
by hypoproteinemia, electrolyte abnormalities (hyponatremia
and hyperkalemia), fat depletion, and immunocompromise from
lymphocyte loss.1,9–11 Patients with chylothorax may also present
with a history of anorexia, lethargy, and weight loss.1,10 Additional
diagnostic evaluation should only be performed once the patient
Figure 5. Fluoroscopic image of the cranial thorax after contrast lymphangiography is in stable condition.
in a normal dog. Multiple collateral TD branches (arrowheads) are seen entering
into circular structures (presumably lymph nodes) or the venous system caudal Thoracic Radiography
to the entry point of the main TD (arrow) at the lymphaticovenous anastomosis.
Small volumes of pleural effusion may form radiopaque pleural
fissure lines from the peripheral margin of the lungs toward the
hilar region. Large amounts of pleural effusion lead to retraction and
“scalloping” of lung lobes (FIGURE 6). Pleural effusion can obscure the
cardiac silhouette, and repeat thoracic radiography after pleural
evacuation may be required to evaluate cardiac size. Chyle is a
bacteriostatic fluid that ir-
ritates the pleural and peri-
cardial surfaces, and chronic Key Points
chylous effusion can lead to
life-threatening fibrosing • Although numerous causes of
pleuritis and pericarditis.12 chylothorax have been reported in
Fibrosing pleuritis should the veterinary literature, an underlying
be suspected when the lungs cause is rarely identified.
are rounded in the presence • Although chyle has a characteristic
of minimal pleural fluid or “milky” appearance, a definitive
when pneumothorax devel- diagnosis of chylothorax can be made
ops after thoracocentesis only if triglyceride levels in the pleural
(FIGURE 7). fluid are greater than those in serum.
Figure 6. Lateral thoracic radiograph of a canine thorax demonstrating soft-tissue
opacity in the pleural space. Note the retraction and scalloping of lung lobes
(arrowheads). Also, the cardiac silhouette is obscured.
Pleural Fluid Evaluation • Chronic chylous effusion can lead to
Thoracocentesis and retriev- life-threatening fibrosing pleuritis
al of pleural fluid is recom- and pericarditis. Fibrosing pleuritis
to the lymphaticovenous anastomosis (FIGURE 5). These findings mended for diagnostic should be suspected when the lungs
provide evidence for the presence of, or the ability to recruit, purposes and to relieve the are rounded in the presence of
collateral lymphatic channels within the thoracic cavity and could patient’s respiratory com- minimal pleural fluid.
explain why chylothorax secondary to elevated central venous promise. Chyle has a char- • TD imaging is recommended before
pressure is rare.6–8 acteristic milky appearance; and after TD ligation. Preoperatively,
however, this appearance it provides the surgeon with a view of
Diagnosis alone cannot be used to TD anatomy, and postoperatively, it
Physical Examination make a definitive diagnosis confirms occlusion of all TD branches.
A complete physical examination often leads the clinician to of chylothorax because other
diagnose pleural effusion. The color of the patient’s mucous effusions, including pyo- • Minimally invasive TD imaging
membranes can vary from normal to pale blue, according to the thorax, may have a similar techniques are associated with less
level of respiratory compromise. Thoracic auscultation may reveal appearance.1 In anorectic morbidity and shorter procedure
reduced heart and lung sounds in the ventral thorax from the patients, chyle may have an times compared with traditional
gravity-dependent accumulation of pleural fluid. Increased broncho- uncharacteristically clear imaging techniques.
vesicular sounds have been found in 45% and 50% of dogs9 and cats10 appearance that can be

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

fluid samples is recommended if

chylothorax is suspected.

Further Diagnostic Evaluation

Once a diagnosis of chylothorax
has been made, the clinician
should attempt to determine
whether there is an underlying
cause. In addition to a complete
blood cell count, serum bio-
chemistry panel, heartworm an-
tigen testing, and coagulation
evaluation, the diagnostic evalu-
ation should include thoracic
A ultrasonography (ideally before
Figure 7. Lateral (A) and dorsoventral (B) thoracic radiographs of a cat thoracocentesis, to provide an
with fluid opacity in the pleural space. The caudal lung lobes are acoustic window) and three-
rounded compared with the normal caudal subsegment of the left view thoracic radiography (after
cranial lung lobe, which maintains a triangular shape. This is indicative pleural evacuation has been per-
of fibrosing pleuritis, in which fibrin deposition on the pleural surface
formed) to determine if there is
prevents normal expansion and contraction of the lungs. B underlying pathology. Thoracic
computed tomography (CT) pro-
misleading.1 If chylous effusion is suspected, further diagnostic vides three-dimensional detail of thoracic structures and can be
tests should be performed to confirm the diagnosis.1,13–15 These combined with preoperative TD imaging.16 As cardiac diseases
tests include cytologic, physical, and biochemical evaluation of are reported causes of chylothorax, a complete cardiac evaluation,
the sampled effusion.1,13–15 including echocardiography, is warranted in all cases. In cats,
Cytologically, chylous effusion contains large numbers of FeLV and FIV testing should also be performed.
small, mature lymphocytes and lower numbers of macrophages
that contain lipid droplets1,14,15 (FIGURE 8). Chylomicrons should Thoracic Duct Imaging
be evident on a wet mount preparation of a chylous effusion.14 In Kagan and Breznock17 first described the use of aqueous contrast
patients with chronic chylothorax that have undergone multiple medium injected directly into a mesenteric lymphatic vessel
thoracocenteses, the effusion can be laden with nondegenerate (mesenteric lymphangiography) for imaging the TD in normal dogs
neutrophils.14,15 This finding could also be a result of the inflam-
matory effect of chyle on the pleura and pericardium. Biochemical
evaluation includes measuring triglyceride, cholesterol, and total
protein levels; performing a total cell count; measuring specific
gravity; and assessing for the presence of chylomicrons.13–15 A
definitive diagnosis of chylothorax is made by comparing triglyceride
levels in paired pleural fluid and serum samples.13–15 In cases of
chylous effusion, the level of triglycerides in the pleural fluid is
greater than that in the serum.13 It is common for the ratio of
triglycerides in pleural fluid to triglycerides in serum to be 10:1 to
20:1 or higher.13–15 The specific gravity and total protein concen-
tration of feline chylous effusion have been reported to be 1.030
to 1.032 and 5.0 to 5.32 g/dL, respectively.9,14 Historically, several
other diagnostic tests have been performed to determine whether
an effusion is chylous.14 These include the ether clearance test and
Sudan II stain, which provide crude estimates of lipid content in
the fluid; however, these tests are seldom used at our institution.
Pleural and serum cholesterol levels can also be compared, with
cholesterol levels being lower in a chylous effusion than in serum.1,14 Figure 8. A cytologic smear (40× magnification) prepared from pleural fluid of a
Although chyle is a bacteriostatic substance, multiple thora- dog with idiopathic chylothorax. The nucleated cells consist of well-preserved
cocenteses for pleural evacuation can increase the risk of developing neutrophils (A ), macrophages (B), medium to large lymphocytes (C), and large
numbers of small lymphocytes (D). Courtesy of Dr. Emmeline Tan
pyothorax. Bacterial culture and sensitivity testing of pleural

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

Figure 9. Intraoperative photo of a dog with idiopathic chylothorax. A celiotomy has

been performed for TD imaging. A mesenteric lymphatic vessel has been cannulated
with an over-the-needle catheter that is sutured in place. Contrast medium can be Figure 10. Lateral thoracic radiograph after contrast lymphangiography in a dog
injected into the catheter for TD imaging using radiography or CT. with idiopathic chylothorax. Branching of the TD is seen in the mid-thorax.

(FIGURE 9). Since that landmark study, several published reports ligation, it does not provide the surgeon with intraoperative infor-
have described the use of mesenteric lymphangiography to high- mation about the TD and its branches. Injection of mesenteric
light the TD in dogs and cats undergoing surgical treatment for lymph nodes or lymphatic vessels with methylene blue is reported
idiopathic chylothorax.1,6,18,19 The most common surgical treat- to facilitate intraoperative visualization of the TD and its branches
ment for idiopathic chylothorax in dogs and cats is TD ligation.20 during TD ligation.20,22 However, intravenous injection of methylene
TD imaging has been recommended before and after TD liga- blue can lead to toxicosis; reported complications include renal
tion.18–20 Preoperative imaging of TD anatomy can allow the surgeon failure, Heinz body anemia, and increased serum alkaline phos-
to ligate the TD at a location with minimal branching in the caudal phatase levels.23,24 Preoperative administration of a fatty meal (oil
thorax, which may optimize surgical success (FIGURE 10). Postop- or 35% cream) to increase the chylomicron content of chyle has
erative lymphangiography can confirm successful occlusion of all also been reported to facilitate intraoperative identification of
TD branches with no flow of contrast cranial to the ligation site lymphatic vessels and the TD.20
so that if postoperative effusion persists, the surgeon can be more The standard imaging modality for mesenteric lymphangiog-
certain that it is not from a failure to occlude all TD branches at raphy has been orthogonal view radiography.17,18 Some authors
the time of surgery. If postoperative lymphangiography reveals question the accuracy of radiographs because superimposition of
persistent TD flow, ligation for the missed TD branch(es) should TD branches and overlying spinal and soft tissue structures can
be reattempted or chylothorax will persist.18,19 make interpretation challenging. In one study25 that compared
Some authors21 have reported concern with the accuracy of post- CT with radiography after direct mesenteric lymphangiography
TD ligation lymphangiography in confirming occlusion of all TD in dogs, CT was found to identify a significantly greater number
branches. In an experimental study in eight cats, six cats had TD of TD branches. The ability to observe TD branches in a three-
ligation performed and two cats had the TD dissected but not ligated dimensional plane and the limited need for patient repositioning
as a sham procedure.21 Immediate postoperative lymphangiography for image acquisition were other advantages of CT identified in
showed no contrast flowing cranial to the site of dissection in all this study.25 CT also has greater contrast resolution, and small,
cats, including the two that did not undergo TD ligation.21 Repeat poorly opacified branches can still be identified (FIGURE 11). The
lymphangiography in the two nonligated cats 4 weeks postoperatively study authors speculated that by improving the ability for surgical
revealed a patent TD. The authors concluded that simply dissecting planning, CT mesenteric lymphangiography would improve success
around the TD was sufficient to cause short-term occlusion of the rates of resolving chylothorax with TD ligation.25
TD.21 Additional studies are required in dogs to determine if dissec-
tion of the TD alone is sufficient to obstruct the flow of contrast at Minimally Invasive Techniques for Thoracic Duct Imaging
the time of lymphangiography. Lymphangiography is challenging to Traditional TD imaging techniques require an exploratory laparoto-
perform in cats and is associated with several limitations, including my and injection of contrast medium into a mesenteric lymphatic
difficulty in locating and injecting mesenteric lymphatic vessels. vessel or lymph node, followed by either radiography or CT.17,18,25
Although radiographic visualization of TD anatomy using The exploratory laparotomy required for mesenteric lymphangi-
aqueous contrast material is advantageous before and after TD ography prolongs anesthesia time and can increase morbidity in

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

A B
Figure 11. Transverse CT image at the level
of the eighth thoracic vertebrae in a normal Figure 12. Lateral radiographs of the pelvic limb (A) and thorax and abdomen (B) after popliteal lymphangiography in a dog
dog after contrast lymphangiography. Three with idiopathic chylothorax. In (A), small lymphatic vessels can be seen travelling from the popliteal lymph node (arrow)
branches of the thoracic duct (arrows) are seen to the medial iliac lymph node (arrowhead). In (B), lymphatic vessels from the medial iliac lymph node (arrowhead) and
dorsal and lateral to the aorta (arrowhead ). abdomen arborize into the CC, from which the TD extends cranially.

an already metabolically compromised chylothorax patient. The TD anatomy after percutaneous popliteal lymphangiography in
goal of developing minimally invasive TD imaging techniques is to normal dogs.16 CT delineated a significantly greater number of
reduce morbidity and anesthesia times and to eliminate the need TD branches compared with both lateral and ventrodorsal radio-
for intraoperative patient transfer to the radiology suite while graphs.16
providing optimal imaging studies to maximize success for the One concern with percutaneous or ultrasound-guided popliteal
veterinary surgeon. lymphangiography is whether enough pressure is generated during
the injection to open all TD branches. This concern is based on
Percutaneous Mesenteric Lymphadenography the fact that high injection pressures cannot be used during this
Ultrasound-guided percutaneous injection of a mesenteric lymph technique and the fact that the popliteal lymph node is much
node with contrast medium followed by thoracic CT has been farther away from the CC and TD compared with mesenteric
reported to produce diagnostic lymphangiograms in dogs.26 The lymphatic branches. Millward et al29 did not find a significant dif-
success of this technique lies in the operator’s experience with ference in TD branches after direct mesenteric and popliteal
ultrasound-guided mesenteric lymph node injection. lymphangiography in normal dogs when CT was used to image
the lymphatic system. Studies support the use of percutaneous
Laparoscopic Mesenteric Lymphadenography popliteal lymphangiography in the perioperative period as a
Laparoscopic surgery has several advantages over laparotomy, minimally invasive alternative to mesenteric lymphangiography
including decreased morbidity, faster recovery, improved visual- or lymphadenography.16,28,29
ization, and improved cosmesis. Laparoscopic mesenteric lymph-
adenography followed by radiography has been described for Conclusion
mesenteric lymph node injection for TD imaging in dogs.27 This The pathogenesis of idiopathic chylothorax remains poorly under-
technique was less successful than direct mesenteric lymphade- stood in veterinary patients. Advances in the diagnostic evaluation
nography (performed via paracostal laparotomy) at producing of chylothorax patients will facilitate the generation of high-quality
diagnostic lymphadenograms, which was attributed to the lack images for presurgical planning with minimal patient morbidity.
of manual stabilization of the injected lymph node, allowing the
node to fall away from the needle during injection.27 References
1. Birchard SJ, McLoughlin MA, Smeak DD. Chylothorax in the dog and cat: a review.
Percutaneous Popliteal Lymphangiography Lymphology 1995;28:64-72.
Percutaneous popliteal lymph node contrast injection has been 2. Drinker CK. Lane Medical Lectures: the lymphatic system. In: University Series: Medical
evaluated in dogs28 (FIGURE 12). Initial studies determined that Sciences. Vol. 4, No. 2. Stanford, CA: Stanford University Press; 1942:137-235.
3. Bezuidenhout AJ. The lymphatic system. In: Evans HE, ed. Miller’s Anatomy of the
the TD could be seen radiographically after experimental injection
Dog. 3rd ed. Philadelphia: WB Saunders; 1993:722-732.
with 1 mL/kg of contrast medium injected at 2 mL/min in dogs.28 4. Swartz MA, Skobe M. Lymphatic function, lymphangiogenesis, and cancer metastasis.
Major complications were not reported with percutaneous popliteal Microsc Res Tech 2001;55:92-99.
lymph node injection.28 In a recent study, CT was used to identify 5. Fossum TW, Miller MW, Rogers KS, et al. Chylothorax associated with right-sided

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heart failure in five cats. J Am Vet Med Assoc 1994;204:84-89. Assoc 1982;18:769-777.
6. Fossum TW, Birchard SJ. Lymphangiographic evaluation of experimentally induced 19. Birchard SJ, Smeak DD, Fossum TW. Results of thoracic duct ligation in dogs with
chylothorax after ligation of the cranial vena cava in dogs. Am J Vet Res 1986;47:967-971. chylothorax. J Am Vet Med Assoc 1988;193:68-71.
7. Blalock A, Cunningham RS, Robinson CS. Experimental production of chylothorax by 20. Fossum TW, Mertens MM, Miller MW, et al. Thoracic duct ligation and pericardectomy
occlusion of the superior vena cava. Ann Surg 1936;104:359-363. for treatment of idiopathic chylothorax. J Vet Intern Med 2004;18:307-310.
8. Lee FC. The establishment of collateral circulation following ligation of the thoracic 21. Martin RA, Richards DL, Barber DL, et al. Transdiaphragmatic approach to thoracic
duct. Johns Hopkins Hospital Bulletin 1922;371:21-31. duct ligation in the cat. Vet Surg 1988;17:22-26.
9. Fossum TW, Forrester SD, Swenson CL, et al. Chylothorax in cats: 37 cases (1969- 22. Enwiller TM, Radlinsky MG, Mason DE, et al. Popliteal and mesenteric lymph node
1989). J Am Vet Med Assoc 1991;198:672-678. injection with methylene blue for coloration of the thoracic duct in dogs. Vet Surg 2003;
10. Fossum TW, Birchard SJ, Jacobs RM. Chylothorax in 34 dogs. J Am Vet Med Assoc 32:359-364.
1986;188:1315-1318. 23. Osuna DJ, Armstrong PJ, Duncan DE, et al. Acute renal failure after methylene blue
11. Willard MD, Fossum TW, Torrance A, Lippert A. Hyponatremia and hyperkalemia infusion in a dog. J Am Anim Hosp Assoc 1990;26:410-412.
associated with idiopathic or experimentally induced chylothorax in four dogs. J Am Vet 24. Fingeroth JM, Smeak DD and Jacobs RM. Intravenous methylene blue infusion for
Med Assoc 1991;199:353-358. intraoperative identification of parathyroid gland and pancreatic islet-cell tumors in
12. Fossum TW, Evering WN, Miller MW, et al. Severe bilateral fibrosing pleuritis associated dogs. Part I: experimental determination of dose-related staining efficacy and toxicity. J Am
with chronic chylothorax in five cats and two dogs. J Am Vet Med Assoc 1992;201:317-324. Anim Hosp Assoc 1988;24:165-173.
13. Fossum TW, Jacobs RM, Birchard SJ. Evaluation of cholesterol and triglyceride con- 25. Esterline ML, Radlinsky MG, Biller DS, et al. Comparison of radiographic and computed
centrations in differentiating chylous and nonchylous pleural effusions in dogs and cats. tomography lymphangiography for identification of the canine thoracic duct. Vet Radiol
J Am Vet Med Assoc 1986;188:49-51. Ultrasound 2005;46:391-395.
14. Fossum TW. Feline chylothorax. Compend Contin Educ Pract Vet 1993;15:549-567. 26. Johnson EG, Wisner ER, Kyles A, et al. Computed tomographic lymphography of the
15. Meadows RL, MacWilliams PS. Chylous effusions revisited. Vet Clin Pathol thoracic duct by mesenteric lymph node injection. Vet Surg 2009;38:361-367.
1994;23:54-62. 27. Brisson BA, Holmberg DL, House M. Comparison of mesenteric lymphadenography
16. Singh A, Brisson BA, Nykamp S, O’Sullivan ML. Comparison of computed tomographic performed via surgical and laparoscopic approaches in dogs. Am J Vet Res 2006;67:168-173.
and radiographic popliteal lymphangiography in normal dogs. Vet Surg 2011;40:762-767. 28. Naganobu K, Ohigashi Y, Akiyoshi T, et al. Lymphography of the thoracic duct by
17. Kagan KG, Breznock EM. Variations in the canine thoracic duct system and the effects percutaneous injection of iohexol into the popliteal lymph node of dogs: experimental
of surgical occlusion demonstrated by rapid aqueous lymphography, using an intestinal study and clinical application. Vet Surg 2006;35:377-381.
lymphatic trunk. Am J Vet Res 1979;40:948-958. 29. Millward IR, Kirberger RM, Thompson PN. Comparative popliteal and mesenteric
18. Birchard SJ, Cantwell HD, Bright RM. Lymphangiography and ligation of the canine computed tomographic lymphangiography of the canine thoracic duct. Vet Radiol Ultra-
thoracic duct: a study in normal dogs and three dogs with chylothorax. J Am Anim Hosp sound 2011;52:295-301.

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 Idiopathic Chylothorax: Pathophysiology, Diagnosis, and Thoracic Duct Imaging

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1. What is the most common cause of chylothorax in dogs and 6. Cytologic evaluation of chylous pleural effusion reveals
cats? a. small, mature lymphocytes and lower numbers of
a. trauma macrophages.
b. cranial vena caval thrombosis b. degenerate neutrophils.
c. idiopathic c. large, immature lymphocytes and lower numbers of
d. cardiac disease macrophages.
d. large, immature lymphocytes and higher numbers of
2. Which of the following is/are not a function(s) of the macrophages.
lymphatic system?
a. maintain fluid balance and act as an adjunct to the 7. A definitive diagnosis of chylothorax can be made when
cardiovascular system a. the ratio of triglycerides in pleural fluid to serum is 10:1
b. generate an immune response against invading pathogens to 20:1.

c. transport dietary fats b. the ratio of cholesterol in pleural fluid to serum is 10:1 to
20:1.
d. regulate circadian rhythm
c. the ratio of triglycerides in serum to pleural fluid is 10:1
3. Which statement(s) is/are correct regarding chyle? to 20:1.
a. It comprises lymphocytes, fat-soluble vitamins, proteins, d. sampled pleural fluid has a characteristic “milky” appearance.
and electrolytes.
8. Repeated thoracocentesis of chylothorax can lead to
b. Chronic loss of chyle into the pleural space can lead to
metabolic and immune compromise. a. restrictive pleuritis.

c. Chyle is an irritant, and chronic exposure of the pleural and b. loculated fluid.
pericardial lining to chyle can lead to fibrosing pleuritis. c. pyothorax.
d. all of the above d. hemothorax.

4. Which statement is correct regarding the TD? 9. Which statement is true concerning TD imaging?
a. It is located in the tissues dorsal to the aorta and ventral a. It is recommended before and after TD ligation.
to the thoracic vertebrae. b. Traditional techniques do not risk increased morbidity.
b. It transports chyle from the CC and empties it into the c. Radiographic and CT lymphangiography are equivalent
venous system at the jugulocaval angle. in delineating TD branching.
c. It can have variable anatomy at the lymphaticovenous d. It does not prolong anesthesia time in the operative
anastotomosis and along its course through the thoracic period.
cavity
d. all of the above 10. Which statement(s) is/are true concerning percutaneous
popliteal lymphangiography?
5. Which statement is correct regarding fibrosing pleuritis? a. It represents a minimally invasive technique for TD imaging.
a. It is a benign condition. b. Followed by CT, it delineates a greater number of TD
b. It can be suspected on radiographs if the lung margins branches than radiography.
are rounded in the presence of minimal pleural effusion. c. It does not delineate as many TD branches as direct
c. It does not affect long-term prognosis. mesenteric lymphangiography.
d. It occurs only in cats. d. a and b

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