subject: HAEMOTHORAX AND ITS CLINICAL FEATURES [print this page] HAEMOTHORAX AND ITS CLINICAL FEATURES HAEMOTHORAX AND ITS CLINICAL FEATURES
Haemothorax is usually the result of a penetrating injuryor blunt trauma to the chest. Occasionally, a haemothoraxdevelops without trauma. Such a spontaneous haemothorax,almost always left-sided, may occur with acute aorticdissection. Bleeding can occur with a pneumothorax, fromthe rupture of vessels within pleural adhesions, and in somecases the air may have been absorbed by the time ofpresentation. Bleeding disorders, heparin therapy, vascularpleural metastases and pleural endometriosis are rarecauses of haemothorax. Haemothoraces, unless small andstable, should be drained by a wide-bore intercostal tubeintroduced in the midaxilla and connected to an underwaterseal. If bleeding continues, the patient requires a thoracotomy.If blood is not removed from the pleural space,infection progressing to empyema can be a complication.In the long term an intense fibrous reaction to undrainedblood can occasionally lead to a grossly thickened pleuraand an encased lung, which then requires decortication ifthere is not to be substantial ventilatory impairment.
Chylothorax most frequently follows rupture of thethoracic duct after trauma, particularly during thoracicsurgery. Damage to the thoracic duct in the lower half ofthe mediastinum causes a right-sided chylothorax, whereasdamage to the duct in the upper mediastinum produces aleft chylothorax. When chylothorax is not due to trauma,malignancy involving the thoracic duct is the most commoncause, particularly metastatic disease from carcinoma ofthe stomach, and lymphoma. Rarely chylothorax cancomplicate chylous ascites.Patients with chylothorax present with symptomsand signs of a large pleural effusion and the diagnosis isonly apparent following aspiration of the milky whitefluid. Fluid rapidly reaccumulates, and repeated drainagesoon leads to severe wasting, hypoproteinaemia andlymphopenia.In up to 50% of patients with chylothorax there is spontaneoushealing of the fistula, but if this does not occur theprognosis is poor unless the leak of chyle can be stopped.Following diagnosis a lymphangiogram is useful to determinethe site of the fistula; if a leak is demonstrated thepatient should be submitted to thoracotomy and ligationof the thoracic duct below the leak. If no leak can bedemonstrated at lymphangiography, repeated aspiration isperformed and the patient is supported by parenteralfeeding, in the hope that the fistula will heal spontaneously.When healing does not take place, pleural drainage combinedwith pleurodesis is sometimes successful.
