Blunt Chest Trauma and Chylothorax: A Systematic Review

Abstract Introduction: Although traumatic chylothorax is predominantly associated with penetrating injuries, instances following blunt trauma, as a rare and challenging condition, are being increasingly documented. This study aims to systematically review the reported cases of blunt chest traumatic chylothorax (BCTC) and provide comprehensive insights into the condition. Methods: Related studies published until December 11, 2024, were identified through Google Scholar. All studies documenting instances of BCTC, without restriction on cause or patient demographics, were included. Studies were excluded if they focused on chylothorax caused by penetrating injuries, their content was unretrievable, they were review articles, or they were published in blacklisted journals. Results: Sixty-five eligible studies, encompassing 69 cases of BCTC, were included in the review. It predominantly affected males (73.91%), with patient ages ranging from 11 months to 84 years old. The most common clinical findings were dyspnea (47.83%) and abnormal auscultation or percussion (34.78%), with road traffic accidents as the primary cause (59.42%). Unilateral chylothorax was found in 72.46% of cases, bilateral chylothorax occurred in 27.54%, and pleural effusion was the most frequent radiological finding (55.07% in X-ray and 33.33% in computed tomography). Treatment typically included drainage (94.20%), parenteral nutrition (50.72%), and thoracic duct closure (39.13%). Most patients achieved complete recovery (89.85%), and six cases (8.70%) died. Conclusion: The condition is rare and complex, underscored by the wide variability in patient demographics, clinical presentations, chylothorax onset, and management approaches. Given the challenges posed by limited evidence, the findings emphasize the need for early recognition and individualized management strategies. Introduction Chylothorax is a rare condition characterized by the accumulation of chyle in the pleural cavity caused by a disruption of the thoracic duct [1]. Chyle is an opalescent fluid that consists of triglycerides, chylomicrons, proteins, electrolytes, immunoglobulins, and fat-soluble vitamins, transported from the gastrointestinal system into the bloodstream by the thoracic duct. It makes up about 1-3% of total body weight in adults. Chylothorax was initially described by Bartolet in 1633 and later reported in the literature by Quinke in 1875 [1,2]. It is categorized into congenital, neoplastic, traumatic, and miscellaneous forms. The most common cause is malignancy, which leads to obstruction of the thoracic duct, while traumatic chylothorax is typically iatrogenic, resulting from surgical procedures or catheter placement. Penetrating trauma is the usual cause of traumatic chylothorax, while blunt trauma is considered an infrequent cause [1,2]. It may also develop due to chest compression or changes in intrathoracic pressure, such as during coughing or persistent vomiting [2]. The incidence of chylothorax is about 0.2% following blunt thoracic trauma and 0.9% after penetrating trauma. Bilateral chylothorax resulting from blunt trauma, mainly when no other injuries are evident, is an infrequent but severe complication [3]. Without prompt treatment, chylothorax can lead to serious complications, such as cardiopulmonary distress and significant nutritional deficiencies, with a high mortality rate of up to 15.5% [2-4]. Although traumatic chylothorax is predominantly associated with penetrating injuries, instances following blunt trauma have been increasingly documented, highlighting the need for awareness among healthcare providers regarding this potential complication [5,6]. This study aims to systematically review the reported cases of blunt chest traumatic chylothorax (BCTC) and provide comprehensive insights into the condition. Methods Literature search The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Related studies published until December 11, 2024, were identified through Google Scholar using a search strategy that combined the following keywords with the “allintitle” and “including citation” features: (blunt trauma chylothorax), (blunt thoracic trauma chylothorax), (blunt thoracic injury chylothorax), (blunt chest injury chylothorax), (blunt torso trauma chylothorax), (blunt thoracic duct trauma), (blunt thoracic duct injury) and (traumatic chylothorax). The search was limited to English-language publications. Eligibility criteria All studies or reports documenting instances of BCTC, without restriction on cause or patient demographics, were eligible for inclusion. Studies were excluded if they focused on chylothorax caused by factors other than blunt chest trauma, if their content was unretrievable, if they were review articles, or if they were published in blacklisted journals. The legitimacy of the studies was verified by cross-referencing with widely recognized predatory journal checklists [7]. Study selection First, an author conducted a literature search using the specified keywords and collected the relevant results. The titles and abstracts of the identified studies were then screened to exclude duplicates, non-English studies, and those unrelated to the study objective. Full-text screening was conducted for studies that passed the initial filtration, excluding those with unretrievable content or irrelevant study designs, such as reviews. This step was supervised by two authors, who independently reviewed each study. Finally, the remaining studies underwent legitimacy filtering. Data extraction The collected data encompassed various parameters, including the first author's name, year of publication, patient demographics, clinical manifestations, causes of chylothorax, chyle volume and content, the onset of chyle production, diagnostic methods, ICU admission status, treatment modalities, outcomes, and follow-up. Statistical Analysis The extracted data were organized in an Excel sheet (2019) and analyzed descriptively using the Statistical Package for the Social Sciences (SPSS, v. 27, IBM Co.). The results were presented in frequencies with percentages, means with standard deviation, and ranges. Results Study identification A systematic search yielded 201 studies, all of which were case reports. After removing duplicates (16) and non-English articles (17), 168 titles and abstracts were screened. Fifty-five case reports were excluded due to irrelevance, and full-text evaluation of the remaining 113 case reports led to the exclusion of an additional 42. Furthermore, six articles were excluded for being published in warning-listed journals. Consequently, 65 eligible case reports, encompassing 69 cases of BCTC, were included in the review [1-6,8-66] (Tables 1 and 2). The identification process is outlined in a PRISMA flowchart (Figure 1). Table 1. Demographic, Cause and Chyle Characteristics First author, year [Reference] Country Age (year) Gender CFP Cause SOC Amount of chyle (ml)/day* COAP (day) Biochemical content of chyle Harvey, 2024 [5] USA 60 F Chest pain, multiple rib fractures RTA Left <500 2 Triglycerides Burduniuc, 2023  [2] Czech Republic 70 F Blunt injury Fall on stairs Right >1000-2000 3 Protein, cholesterol, triglycerides Dung, 2023 [14] Vietnam 32 M Thoracic spine injury, paraplegia RTA Right >1000-2000 At once Cholesterol, triglycerides Kim, 2023 [4] South Korea 45 M Hemodynamically unstable, chest discomfort, multiple fractures, hemopneumothorax Crushed by a 2-ton metal frame Left >1000-2000 1.66 Triglycerides Boateng 2023   [33] USA 75 F Respiratory distress Fall from bed Right <500 At once Triglycerides Ruest 2023 [34] USA 15 months M Tenderness over right paraspinal thoracolumbar back, abnormal auscultation Child abuse Right N/A At once N/A Mohanakrishnan 2022 [35] USA 70 F Dyspnea, back pain, abnormal auscultation Violent coughing episode Right >1000-2000 At once Chylomicrons, triglycerides Mazhar, 2021[23] UK 42 F Dyspnea, abnormal auscultation Fall from horse 1 week before presentation Right >1000-2000 7 Triglycerides Waseem, 2021[32] Pakistan 50 M Dyspnea RTA 2 days before presentation Bilateral >1000-2000 2 Triglycerides, cholesterol, fat-rich fluid with few inflammatory cells Din Dar 2021   [36] India 50 M Blunt injury RTA Right >1000-2000 25 Triglyceride, chylomicrons Bacon, 2020 [9] USA 53 M Hemopneumothorax RTA Left <500 5 N/A Champion, 2020  [12] Canada 29 M Dyspnea, flushing, diaphoresis, vomiting, abnormal auscultation RTA Bilateral >1000-2000 At once Cholesterol, triglycerides Jindal 2019 [37] India 35 M Dyspnea, respiratory distress RTA Bilateral >1000-2000 4 Triglyceride, WBC, albumin, glucose, protein, LDH Ahmed, 2018 [1] Iraq 42 M Severe back pain RTA Right 500-1000 2 Triglycerides and lymphocyte Brown, 2018 [10] USA 53 M Thoracoabdominal injuries, subcutaneous emphysema, unstable pelvis RTA Left >1000-2000 N/A Triglycerides and lymphocyte Litzau, 2018 [22] USA 66 F Dyspnea, multiple fractures, abnormal auscultation RTA 7 days before presentation Right >1000-2000 7 Triglycerides Kozul, 2017 [19] Australia 18 M Multiple injuries RTA Bilateral 500-1000 0.46 N/A Lee, 2017 [21] South Korea 70 M Hemothorax, flail chest RTA Right >2000 5 Triglycerides, cholesterol Mohamed, 2017  [3] USA 51 M Dyspnea, chest pain, abnormal auscultation Fall on stairs Bilateral >1000-2000 5 Triglycerides, Leukocytes, RBCs, LDH, protein Spasić, 2017 [6] Serbia 55 F Multiple injuries RTA Right >2000 5 N/A Sriprasit, 2017   [31] Thailand 27 F Hemothorax, neurogenic shock, multiple fractures RTA Left <500 5  Triglycerides, protein, glucose, LDH Hara 2017 [38] Japan 17 F Breathing difficulty, abnormal percussion Recurrent chylothorax, physical punishment Left 500-1000 At once N/A Jahn 2017 [39] Germany 8 F Respiratory distress, abnormal percussion, and auscultation Pedestrian hit by a motor vehicle Left <500 5 Protein, albumin, LDH, triglycerides, cholesterol Ghodrati 2016   [40] Iran 12 F Dyspnea, respiratory distress Chest trauma during play at school Bilateral N/A N/A N/A Lee 2016 [41] South Korea 50 M Paraplegia Fall from height during construction work Right >1000-2000 3 Triglycerides Sendama 2015   [42] UK 84 F Dyspnea, abnormal auscultation  Fall Right 500-1000 4 Protein, LDH, cholesterol, triglycerides Snow 2015 [43] USA 22 months M Cough, dyspnea, respiratory distress, altered mental status, abnormal auscultation Fall from a chair Right <500 2 Triglycerides Adams 2013 [44] USA 73 M Paraplegia, rib fractures, hemothorax RTA Right N/A 9 Triglycerides, lymphocytes, glucose, LDH, lipemia Kumar 2013 [45] India 32 M Blunt injury, fracture of right femur RTA Right >1000-2000 2 Triglycerides, chylomicrons 23 M Hemopneumothorax, multiple rib fractures, subcutaneous emphysema RTA Right 500-1000 1  Triglycerides 40 M Hemothorax RTA Right 500-1000 2  Triglycerides Sharkey 2012   [46] UK 50 M Multiple fractures, hematoma, hemothorax, pneumothorax RTA Right 500-1000 N/A Triglyceride, cholesterol Sokouti, 2011[30] Iran 15 M Respiratory distress, dyspnea, back pain, abnormal auscultation Fall 11 years ago Bilateral >2000 40 Triglycerides, protein, cholesterol, fat Kurklinsky 2011   [47] USA 26 F Pleuritic chest pain Water-skiing fall Bilateral >1000-2000 2 Triglycerides Apostolakis, 2009 [8] USA 75 F Dyspnea, back pain RTA Bilateral 500-1000 At once Protein, LDH, glucose, amylase, triglycerides, cholesterol, albumin, globulin, K, Na, lymphocytes, erythrocytes 22 M Back pain, hematoma of left thigh, chest pain RTA Bilateral <500 0.25 Protein, LDH, glucose, amylase, triglycerides, cholesterol, albumin, globulin, K, Na, lymphocytes, erythrocytes Huber, 2009 [16] USA 47 M Dyspnea, chest pain Crushed by multiple metal gates Bilateral 500-1000 3 Triglycerides Schurz, 2009   [28] Austria 39 M Dyspnea, thoracodorsal pain RTA Left >1000-2000 14 N/A Serin-Ezer, 2009 [29] Turkey 4 M Dyspnea, somnolence, abnormal auscultation Hit by a manufacturing pipe falling from a truck Bilateral <500 At once Triglycerides, cholesterol, protein, LDH, glucose Kamiyoshihara, 2008 [18] Japan 51 M Dyspnea, dullness in percussion RTA 20 years before presentation Bilateral >1000-2000 At once (but the trauma dated back to 20 years prior)   Triglycerides Pandey 2008  [48] Australia 36 M Chest pain, flail chest, hypotension Fall from balcony Right >1000-2000 2 N/A Lee, 2006 [20] South Korea 11 M Dyspnea, nausea, vomiting, abdominal discomfort, abnormal auscultation RTA 3 days before presentation Bilateral N/A 3 Triglycerides, cholesterol, protein Ozcelik, 2004   [26] Turkey 15 F Respiratory distress, subcutaneous emphysema, pneumothorax Trapping under rubble during a 7.8 magnitude earthquake Right N/A 45 Cholesterol, triglycerides Robbins 2004   [49] USA 41 M Chest injury, refractory hiccups, nausea RTA Bilateral N/A N/A N/A Buchan 2001   [50] UK 18 M Dyspnea RTA Right >1000-2000 4 N/A Chamberlain, 2000 [11] UK 29 M Pneumothorax, abdominal and paraspinal pain, loss of motor power, and sensation below T12/L1 RTA Right >1000-2000 0.88 N/A Glyn-Jones 2000 [51]   UK 28 M Dyspnea, polytrauma, tachypnea RTA Left >2000 N/A Triglyceride, cholesterol, WBC Golden, 1999  [15] USA 53 F Chest pain, multiple fractures, hemopneumothorax, abnormal auscultation RTA Left >2000 6 Triglycerides McCormick, 1999 [24] USA 46 M Chest pain, dyspnea, abnormal auscultation, dullness to percussion Hit-and-run motor vehicle accident Bilateral >1000-2000 14 Protein, cholesterol, triglycerides Ikonomidis, 1997 [17] Canada 17 M Closed head injury, multiple fractures, respiratory distress, tracheal hematoma RTA Bilateral <500 At once Triglycerides 24 M Closed head injury, rib fractures, hemothorax Snowboarding accident Left <500 At once Triglycerides Guleserian, 1996 [52] USA 11 months M Dyspnea, coughing, cold symptoms, grunting, abnormal percussion Child abuse Right 500-1000 N/A Triglycerides, cholesterol, WBC Milano, 1994 [25] Italy 26 F Dyspnea Fall while skiing 4 months prior Left >1000-2000 50 Triglycerides Fogli, 1993 [53] Italy 31 M Suspected traumatic hemothorax, dyspnea, cough RTA Right 500-1000 N/A N/A Grant, 1991 [54] New Zealand 32 M Dyspnea, chest and back pain RTA Right >1000-2000 N/A N/A Dulchavsky, 1988 [13] USA 48 M Dyspnea, chest pain, abnormal auscultation Fistfight Right >1000-2000 At once Cholesterol, HDL, triglycerides, pre-beta lipoprotein, chylomicrons Brook 1988 [55] USA 27 M Respiratory distress, abnormal percussion, tachycardia RTA Bilateral >2000 3 Triglycerides   Pai, 1984 [27] USA 19 M Neck, back, and chest pain RTA Right >1000-2000 N/A N/A Krishnan 1982   [56] Malaysia 29 M Dyspnea, abnormal percussion RTA Right >2000 2 N/A Azambuja 1981   [57] Brazil 42 M Paraplegia, hemopneumothorax RTA Right N/A 3 N/A Rea 1960 [58] UK 28 M Dyspnea, apex beat displaced to the left Crush injury from falling planks Right 500-1000 4 Lipid, protein, RBC, lymphocytes Guest 1955 [59] Canada 19 M Dyspnea, dry cough, tachypnea, dull percussion RTA Right >1000-2000 26 N/A Elliot 1948 [60] Canada 56 M Fall injury, paraplegia, respiratory distress Fall from a tree Right 500-1000 3 Fat Dorsey 1942 [61] USA 60 M Alcoholic stupor, dyspnea, chest pain, abnormal percussion Fall down a flight of stairs Right >2000 0.5 Protein, albumin, globulin, fat Cellan-Jones 1940 [62] UK 32 M Dyspnea, chest tightness A stone hitting the chest and dorsal spine striking a block of coal Right >1000-2000 3 Fat Brown 1937 [63] USA N/A F Respiratory distress, abdominal distention RTA Bilateral >1000-2000 At once N/A Bauersfeld 1937   [64] USA 22 M Breathing difficulty, laceration of the scalp, pain in lower abdomen and lumbar region, cyanosis, cold extremities RTA Right >2000 8 Fat globules Lillie 1935 [65] USA 45 M Blunt injury Fall from a scaffold 20 feet high Right >2000 N/A N/A Macnab 1932   [66] Canada 46 M Chest and back pain, dullness percussion, dyspnea, anorexia, weakness, intermittent fever, hypotension Fall from a height of 11 feet Right 500-1000 6 N/A F: female, M: male, CFP: clinical findings & presentation, SOC: Side of chylothorax, hr: hour, N/A: non-available, COAP: Chyle onset after presentation, RTA: road traffic accident, RBC: red blood cell, LDH: lactate dehydrogenase, HDL: high density lipoprotein, WBC: white blood cell.   * The amount of chyle has been grouped rather than the actual amount. Table 2.  Imaging findings, treatment and outcomes. First author, year [Reference] Chest X-ray CT MRI ICU admission Treatment Thoracic duct ligation approach Mode of drainage Duration of chest tube placement (day) Follow-up (weeks) Outcome Harvey, 2024 [5] Pleural effusion Hemopneumothorax, pneumomediastinum, retrosternal hematoma, multiple rib fracture, lung contusions, and manubrium fractures N/A Yes Drainage, medium chain fatty acid diet N/A Chest tube 7 8 Recovered Burduniuc, 2023   [2] Pleural effusion, multiple rip fracture Pleural effusion, multiple rib fracture Th12 vertebral fracture Yes Drainage, thoracic duct ligation Thoracotomy Chest tube N/A N/A Recovered Dung, 2023 [14] Pleural effusion T9 and T10 vertebral fracture N/A No Drainage, octreotide, TPN, thoracic duct embolization 2.7 Fr microcatheter, fluoroscopic guidance Chest tube 7 N/A Recovered Kim, 2023 [4] Pleural effusion Lipiodol leakage near T10–11 level N/A Yes Drainage, TPN, intranodal lymphangiography, therapeutic lipiodol injection N/A Chest tube 39 N/A Recovered Boateng 2023   [33] N/A Pleural effusion, lung collapse N/A No Drainage, medium-chain triglyceride N/A Chest tube N/A N/A Died Ruest 2023 [34] Pleural effusion  T12 vertebral body fracture, rib fractures N/A Yes Drainage N/A Chest tube N/A N/A Recovered Mohanakrishnan 2022 [35] N/A Pleural effusion, minimal ascites N/A No Drainage, octreotide, low-fat diet, NPO, TPN, pleurodesis, thoracic duct embolization Coiling and glue embolization Chest tube N/A N/A Recovered Mazhar, 2021[23] Pleural effusion Pleural effusion, T10 spinous process fracture N/A No Drainage, octreotide, medium-chain triglyceride diet N/A Chest tube 3 N/A Recovered Waseem, 2021[32] Pleural effusion Pleural effusion N/A No Only drainage N/A Chest tube 5 N/A Recovered Din Dar 2021   [36] N/A Multiple rib fractures, hemothorax N/A No Drainage, NPO, TPN, octreotide, thoracic duct embolization Thoracotomy Chest tube 25 48 Recovered Bacon, 2020 [9] Multiple rib fracture Multiple rib fracture N/A Yes Drainage, free-fat diet N/A Chest tube N/A 12 Recovered Champion, 2020   [12] Pleural effusion Pleural effusion N/A No Drainage, octreotide, TPN, thoracic duct ligation Thoracotomy Chest tube N/A 6 Recovered Jindal 2019 [37] Pleural effusion Multiple rib fractures, lung contusions, fracture of L1 and L2 vertebrae N/A Yes Drainage, thoracic duct ligation, TPN, octreotide, fat-free and medium chain triglyceride Thoracotomy Chest tube 8 8 Recovered Ahmed, 2018 [1] Opacification of hemithorax D10 vertebral fracture, multiple rib fracture N/A Yes Drainage, low-fat diet, albumin vial, octreotide N/A Chest tube       Brown, 2018 [10] N/A Left temporal epidural hematoma, pulmonary contusions, multiple skeletal fractures, pneumomediastinum compressing the right atrium Not mentioned the findings No Drainage, NPO, TPN, octreotide, thoracic duct embolization, and ligation Thoracotomy, decortication Chest tube       Litzau, 2018 [22] Pleural effusion Pleural effusion N/A No Drainage, low-fat diet N/A Chest tube       Kozul, 2017 [19] N/A Hemopneumothorax, mediastinal shift to the right, pleural effusion N/A No Drainage, No fat/low-fat diet N/A Chest tube       Lee, 2017 [21] Pleural effusion Multiple rib fracture, hemopneumothorax (left), subcutaneous emphysema (left), and atelectasis (right). N/A Yes Drainage, TPN, NPO, fat-free diet, medium-chain lipid diet, thoracic duct ligation, pleurectomy Thoracotomy Chest tube       Mohamed, 2017   [3] Obliteration of left costophrenic angle (pleural effusion) Bilateral effusion N/A No Drainage, fat-free diet with medium-chain triglycerides, octreotide N/A Thoracentesis       Spasić, 2017 [6] Lung contusion Rib and thoracic vertebral fracture, hydropneumothorax, lung contusion, pneumomediastinum N/A No Drainage, TPN, thoracic duct suturing Thoracotomy Chest tube       Sriprasit, 2017   [31] N/A N/A N/A Yes Drainage, NPO, TPN N/A Chest tube       Hara 2017 [38] Pleural effusion N/A N/A No Drainage, low-fat diet with medium-chain triglycerides, intranodal lymphangiography with lipiodol N/A Chest tube       Jahn 2017 [39] Pulmonary opacification Lung contusions N/A No Drainage, fat-free diet N/A Chest tube       Ghodrati 2016   [40] Pleural effusion N/A N/A Yes Drainage, thoracic duct embolization Unknown Chest tube       Lee 2016 [41] N/A Incomplete cord injury at the thoracic spinal vertebrae (T10 and T11) N/A No Drainage, TPN, NPO, thoracic duct ligation VATS Chest tube       Sendama 2015   [42] Pleural effusion Multisegment fracture of L1 vertebra N/A No Drainage, medium chain fatty acid diet, octreotide N/A Chest tube       Snow 2015 [43]  Opacification of right chest, mediastinal shift to left N/A N/A Yes Drainage, NPO, TPN, octreotide, low-fat diet N/A Chest tube       Adams 2013 [44] Pleural effusion, atelectasis Pleural effusion, atelectasis N/A Yes Drainage, NPO, TPN, octreotide N/A Thoracentesis, chest tube       Kumar 2013 [45] N/A Pleural effusion, multiple rib fractures N/A No Drainage, NPO, TPN, octreotide, chest physiotherapy N/A Chest tube       N/A Hemopneumothorax, multiple rib fractures N/A No Drainage, NPO, TPN, octreotide, chest physiotherapy N/A Chest tube       N/A Bilateral hemothorax, lung contusion N/A Yes Drainage, NPO, TPN, octreotide, exploratory laparotomy for biliary leak N/A Chest tube       Sharkey 2012   [46] N/A N/A N/A Yes Drainage, NPO, TPN, octreotide, medium fatty acid diet N/A Chest tube       Sokouti, 2011[30] Large cystic mass in left posterior mediastinum Large low-density cystic mass in the left posterior mediastinum, left pleural effusion N/A No Drainage, thoracic duct ligation, TPN Laparotomy, Thoracotomy Chest tube       Kurklinsky 2011   [47] N/A  Pleural effusion, dilated cisterna chyli, middle mediastinum fluid collection N/A No Drainage, TPN, thoracic duct embolization 3 Fr microcatheter with ultrasound guidance Thoracentesis       Apostolakis, 2009 [8] Pleural effusion Pleural effusion N/A No Drainage, starvation diet, TPN N/A Chest tube       Pleural effusion, rib fractures, ipsilateral sternoclavicular joint dislocation Lung contusion N/A No Drainage, starvation diet, TPN N/A Chest tube       Huber, 2009 [16] Pleural effusion Pleural effusion, right pneumothorax, multiple rib fracture, aortic pseudoaneurysm, retrocrural hemorrhage N/A Yes Drainage, thoracic duct ligation, medium chain fatty acid diet, mechanical pleurodesis Thoracotomy Chest tube       Schurz, 2009   [28] Multiple rib fracture, pleural effusion Pleural effusion Osseous lesions and pleural effusion Yes Drainage, TPN, fat-free diet, plain tea, apple puree N/A Pleural puncture, chest tube       Serin-Ezer, 2009 [29] Multiple rib fracture, pleural effusion Pleural effusion N/A No Drainage, NPO, TPN N/A Chest tube       Kamiyoshihara, 2008 [18] Pleural effusion Pleural effusion N/A No Drainage, low-fat diet, TPN, thoracic duct ligation, pleurodesis Thoracotomy Thoracentesis, Chest tube       Pandey 2008  [48] N/A Hemopneumothorax, pulmonary contusion, multiple rib fractures, pneumomediastinum N/A Yes Drainage, octreotide, thoracic duct ligation Laparoscopic ligation Chest tube       Lee, 2006 [20] Elevation of diaphragms, cardiomegaly Pleural effusion, massive ascites around liver and spleen N/A No Drainage, medium-chain lipid solution, NPO N/A Thoracentesis, chest tube       Ozcelik, 2004   [26] Pneumothorax, consolidated right lung, pleural effusion Right lung consolidation, pleural effusion N/A No Drainage, thoracic duct mass ligation, TPN Thoracotomy Chest tube       Robbins 2004   [49] N/A Pleural effusion, focal fluid collection N/A No EUS-guided aspiration, injection of sodium morrhuate N/A Aspiration       Buchan 2001   [50] Pleural effusion N/A   N/A No Drainage, low-fat diet, medium-chain triglycerides, thoracic duct ligation Thoracotomy Chest tube       Chamberlain, 2000 [11] Pneumothorax, hemithorax opacification Free abdominal gas Fractures of T4 and T10 with spinal cord contusion and hematoma No Drainage, TPN, NPO, Supradiaphragmatic duct ligation Thoracotomy Chest tube       Glyn-Jones 2000 [51]   Mediastinal shift Minor anterior wedge fractures at T5 and T10 Cord injury at T10 No Drainage, thoracic duct ligation, pleurodesis, fat-free diet Thoracotomy Chest tube       Golden, 1999   [15] N/A N/A N/A Yes Drainage, TPN, NPO, thoracic duct ligation Thoracotomy Chest tube       McCormick, 1999 [24] Pleural effusion Disruption of the thoracic duct at the T5 level N/A No Only drainage N/A Chest tube       Ikonomidis, 1997 [17] Pneumomediastinum, pulmonary contusions N/A N/A No Drainage, TPN, bowel rest N/A Chest tube       Left hemothorax Left mediastinal hematoma, T3 vertebral fracture N/A No Drainage, TPN, bowel rest N/A Chest tube       Guleserian, 1996 [52]   Right lung opacification and mediastinal shift to left N/A N/A No Drainage, nasogastric feeding with medium-chain triglycerides, low-fat diet N/A Chest tube       Milano, 1994 [25] Pleural effusion Dense lymphatic opacification at L1-L2, chyloma at D11, pleural leakage from left duct N/A No Drainage, low-fat diet, medium-chain triglycerides, TPN, pleuroperitoneal shunt N/A Thoracentesis       Fogli, 1993 [53] Pleural effusion, mediastinal shift N/A N/A No Drainage, TPN N/A Chest tube       Grant, 1991 [54] Pleural effusion N/A N/A No Drainage, thoracic duct ligation, TPN, low-fat diet Thoracotomy Thoracocentesis, chest tube       Dulchavsky, 1988 [13] Pleural effusion N/A N/A No Drainage, TPN, NPO, thoracic duct ligation Thoracotomy Chest tube N/A 144 Recovered Brook 1988 [55] Pleural effusion N/A N/A Yes Drainage, NPO, TPN, low-fat/ high-protein diet N/A Chest tube 10 32 Recovered Pai, 1984 [27] Fracture dislocations of C6-C7 and T11-T12, right hemothorax N/A N/A No Drainage, fat-free diet, TPN, thoracic duct ligation, parietal pleurectomy Thoracotomy Chest tube N/A N/A Recovered Krishnan 1982   [56] Pleural effusion, obliteration of left costophrenic angle, multiple rib fractures N/A N/A No Drainage, thoracic duct ligation Thoracotomy Chest tube 19 5 Recovered Azambuja 1981   [57] Hemopneumothorax N/A N/A No Drainage, thoracic duct ligation, pleural flap to address fistula, pleural abrasion Thoracotomy Chest tube 6 N/A Recovered Rea 1960 [58] Opaque hemithorax N/A N/A No Drainage, thoracic duct ligation Thoracotomy Chest tube N/A N/A Recovered Guest 1955 [59] N/A N/A N/A No Aspiration, high-protein, low-fat diet N/A Thoracentesis N/A 4 Recovered Elliot 1948 [60] Pleural effusion N/A N/A No Aspiration, thoracic duct ligation Thoracotomy Aspiration N/A N/A Recovered Dorsey 1942 [61] Rib fracture, pleural effusion N/A N/A No Drainage, low-fat diet, high-carb, high-protein diet, NPO N/A Thoracentesis N/A N/A Died due to uncontrolled leakage Cellan-Jones 1940 [62] Pleural effusion N/A N/A No Aspiration, low-fat diet, intravenous glucose-saline N/A Aspiration N/A N/A Died due to uncontrolled leakage Brown 1937 [63] Pleural effusion N/A N/A No Drainage, dietary management N/A Thoracentesis, paracentesis N/A N/A Died Bauersfeld 1937   [64] Pleural effusion, mediastinal shift N/A N/A No Drainage, intravenous dextrose, high-calorie diet N/A Thoracentesis 16 N/A Recovered Lillie 1935 [65] Pleural effusion, mediastinal displacement N/A N/A No Drainage, fat-free diet N/A Thoracentesis N/A N/A Recovered Macnab 1932   [66] Displacement of the heart, pleural effusion N/A N/A No Drainage, carbohydrates, protein N/A Aspiration 48 2 Died due to extreme asthenia CT: computed tomography, MRI: magnetic resonance imaging, ICU: intensive care unit, NPO: Nulla Per Os, TPN: total parenteral nutrition, N/A: non-available, EUS: endoscopic ultrasound Presentation and etiology The patients ranged in age from 11 months to 84 years, with a mean of 37.4 ± 19.9 years. Most cases were male (73.91%), while females accounted for 26.09%. The most common presenting symptom or clinical findings were dyspnea, observed in 47.83% of cases, followed by abnormal findings on auscultation or percussion (34.78%) and multiple fractures or injuries (27.54%). Other frequent symptoms included chest pain (21.74%) and pneumothorax, hemothorax, or hemopneumothorax (20.29%). Road traffic accidents (RTA) were the most prevalent cause of BCTC, accounting for 59.42% of cases, followed by falls (23.19%), trauma caused by heavy objects (8.70%), physical punishment or child abuse (4.34%), and fistfights (1.45%). Bilateral chylothorax was observed in 27.54% of cases, while 55.07% had right-sided involvement and 17.39% had left-sided involvement. The chyle leakage ranged widely, which was >1000–2000 mL/day in 40.58% of cases. Smaller volumes (<500 mL/day) were noted in 14.50% and 500 – 1000 mL/day in 20.28%. In 14.50% of cases, >2000 mL/day was drained. Chyle onset occurred within two days of presentation in 40.58% of cases and within three days to a week in 31.88%. Delayed onset (beyond one week) was reported in 13.04% of cases. The chyle predominantly contained only lipids (40.57%). Other compositions included lipid-protein mixtures (11.59%) and lipid-inflammatory cells (7.24%). Complex mixtures of lipids, proteins, sugars, inflammatory cells, and ions were seen in smaller proportions (5.80%) (Table 3). Table 3. Summary of findings of the reviewed cases Variables Frequency / Percentage Patient demography Age range (mean ± SD), years 11 months – 84 (37.4 ± 19.9) Gender  Male  Female   51 (73.91%) 18 (26.09%) Common presentation and clinical findings*   Dyspnea  Abnormal auscultation or percussion  Multiple fractures or injuries  Chest pain  Pneumothorax/ hemothorax/ hemopneumothorax  Back pain  Respiratory distress   33 (47.83%) 24 (34.78%) 19 (27.54%) 15 (21.74%) 14 (20.29%) 11 (15.94%) 11 (15.94%) Cause of blunt trauma  Road traffic accident  Fall  Hit or crushed by heavy objects  Physical punishment & child abuse  Fistfight  Others   41 (59.42%) 16 (23.19%) 6 (8.70%) 3 (4.34%) 1 (1.45%) 2 (2.90%) Side of chylothorax  Right  Left  Bilateral   38 (55.07%) 12 (17.39%) 19 (27.54%) Amount of chyle (ml/day)  <500  500 - 1000  >1000-2000  >2000  N/A   10 (14.50%) 14 (20.28%) 28 (40.58%) 10 (14.50%) 7 (10.14%) Chyle onset after presentation (day)  At once – 2 days    3 days – one week  > one week – one month  > one month  N/A   28 (40.58%) 22 (31.88%) 6 (8.70%) 3 (4.34%) 10 (14.50%) Biochemical content of chyle  Lipid  Lipid + Protein  Lipid + Inflammatory cells  Lipid + Protein + Sugar + Inflammatory cells + Ions  Lipid + Protein + Sugar  Lipid + Inflammatory cells + Protein  N/A   28 (40.57%) 8 (11.59%) 5 (7.24%) 4 (5.80%) 2 (2.90%) 2 (2.90%) 20 (29.00%) Imaging findings   Chest X-rays*  Pleural effusion  Rib Fracture  Lung/ mediastinal/ heart shift  Opacification of lung  Pneumothorax/ hemothorax  Lung contusion  Pneumomediastinum  Vertebral fracture  Lung consolidation  Others  N/A   38 (55.07%) 7 (10.14%) 7 (10.14%) 6 (8.70%) 5 (7.24%) 2 (2.90%) 1 (1.45%) 1 (1.45%) 1 (1.45%) 5 (7.24%) 15 (21.74%) CT scan findings*  Pleural effusion  Rib fracture  Vertebral fracture  Pneumothorax/ hemothorax/ hemopneumothorax  Lung contusion  Pneumomediastinum  Hematoma  Thoracic duct leakage  Others  N/A   23 (33.33%) 14 (20.29%) 10 (14.50%) 9 (13.04%) 8 (11.59%) 4 (5.80%) 3 (4.34%) 2 (2.90%) 17 (24.64%) 25 (36.23%) ICU admission  Yes  No   19 (27.54%) 50 (72.46%) Common treatment approach*  Drainage  Parenteral nutrition  Thoracic duct ligation/embolization/suturing  Medium-chain fatty acid or low-fat diet  Nulla per Os  Free fat diet/starvation diet  Octreotide  Pleurectomy/Pleurodesis   65 (94.20%) 35 (50.72%) 27 (39.13%) 24 (34.78%) 19 (27.54%) 12 (17.39%) 17 (24.64%) 6 (8.70%) Thoracic duct closure approach  Thoracotomy  Fr microcatheter with fluoroscopic/ ultrasound guidance  VATS/ laparoscopy  Coiling and glue embolization  Unknown  Not performed   22 (31.88%) 2 (2.90%) 2 (2.90%) 1 (1.45%) 1 (1.45%) 41 (59.42%) Mode of drainage  Chest tube  Thoracentesis  Aspiration  Chest tube + Thoracentesis   53 (76.81%) 9 (13.04%) 4 (5.80%) 3 (4.34%) Duration of chest tube placement  ≤ One week  > One week – two weeks  > Two weeks – one month  > One month  N/A   12 (17.39%) 11 (15.94%) 13 (18.84%) 4 (5.80%) 29 (42.03%) Outcome  Recovered  Partially recovered  Died   62 (89.85%) 1 (1.45%) 6 (8.70%) SD: standard deviation, CT: computed tomography, ICU: intensive care unit, VATS: video-assisted thoracoscopic surgery, N/A: non-available.  *Each data in the variable might be found in more than one case Imaging characteristics and management Chest X-rays revealed pleural effusion in 55.07% of cases, rib fractures, and lung or mediastinal or heart shift, each in 10.14%, lung opacification in 8.70%, and pneumothorax or hemothorax in 7.24%. Computed tomography (CT) scans confirmed pleural effusion in 33.33% and rib fractures in 20.29%. The vertebral fracture was found in 14.50%, and pneumothorax, hemothorax, or hemopneumothorax in 13.04%. Drainage was performed in 94.20%, predominantly via chest tubes (76.81%). In 17.39% of patients, the chest tube was in place for one week or less, while 15.94% required chest tube placement for more than one week until two weeks. Another 18.84% needed chest tube placement for over two weeks to one month, and 5.80% had chest tube placement exceeding one month. Additional treatments included parenteral nutrition (50.72%), thoracic duct closure (39.13%), and dietary modifications such as a medium-chain fatty acid or low-fat diet (34.78%). Pharmacological treatments included octreotide in 24.64% of cases. Thoracic duct closure was performed through thoracotomy in 31.88%. Other less-used techniques included Fr microcatheter under radiological guidance in 2.90%, video-assisted thoracoscopy or laparoscopy in 2.90%, and coiling and glue embolization in 1.45%. In 59.42% of cases, thoracic duct closure was not performed. The majority of patients (89.85%) achieved complete recovery, with one case showing partial recovery (1.45%), and six cases died (8.70%) (Table 3). Discussion Chylothorax is a pathological condition; if left untreated, it can result in respiratory distress and various complications. The etiology is multifaceted, including traumatic causes, while non-traumatic factors may involve conditions that elevate lymphatic pressure or cause obstruction, such as lymphoma or heart failure [1,67]. Chylothorax was first documented in the medical literature during the 19th century but has since garnered increasing recognition with advancements in diagnostic and surgical techniques. Improved imaging modalities and surgical innovations have significantly enhanced the understanding of its pathophysiology, facilitating more effective identification and management of its underlying causes [1,2].  The demographic data in the present review revealed an age range of 11 months to 84 years, with a mean age of 37.4 ± 19.9 years. This aligns with the literature, as Elsaied et al. reported an approximate mean age of 42.67 years within an age range of 18 to 76 years [68]. Case reports have identified young adults as particularly susceptible to chylothorax following blunt chest trauma, who are commonly involved in motor vehicle collisions or sports injuries [12,31]. Conversely, another study found that individuals aged 50 years or older represented the most common age group among blunt chest trauma patients, comprising 28.9% of the sample [69]. This reflects the increased risk of falls and accidents among older populations [70]. The slightly lower mean age in the present study may be attributable to the inclusion of pediatric cases, broadening the demographic scope. A significant male predominance was observed in the current review, with 73.91% of cases involving males. This finding concurs with the literature, where male representation ranged from 72.3% in a literature review [71] to 85.4% in a cohort study on blunt chest trauma cases [69]. This gender disparity is often linked to higher exposure to high-risk activities and occupations among males [12,31]. The clinical presentation of chylothorax is variable, with dyspnea being the most common symptom, reported by approximately 66.7% of patients. Dyspnea arises from fluid accumulation in the pleural space, which restricts lung expansion and impairs gas exchange. Patients may also experience a dry cough, often exacerbated by pleural fluid [72]. Pleuritic chest pain is another potential symptom, likely caused by pleural irritation from chyle [3,5]. On physical examination, percussion of the thorax often reveals dullness over the affected area due to fluid accumulation, contrasting with the typical resonance of healthy lung tissue [3,12,22]. Auscultation typically shows diminished or absent breath sounds over regions where fluid has accumulated, reflecting impaired air movement [72]. In this review, consistent with the literature, dyspnea was the most common presenting symptom (47.83%). This was followed by abnormal findings on auscultation or percussion in 34.78% of cases. Other frequently reported symptoms included chest pain (21.74%) and complications such as pneumothorax, hemothorax, or hemopneumothorax (20.29%). The thoracic duct, the primary conduit for lymphatic fluid, can be ruptured or injured by blunt trauma, leading to chyle leakage into the pleural space [71,73]. Damage to adjacent structures, such as vertebral fractures or mediastinal injuries, can also contribute to chylothorax. For example, thoracic spine injuries have been associated with chylothorax due to their anatomical proximity to the thoracic duct [4,14]. Chylothorax is predominantly unilateral. In a study of 74 cases, 78% involved one hemithorax, with the right side being affected in 67% and the left in 33%. Bilateral pleural effusion was observed in 22% of cases [74]. The volume of chyle leakage varies based on the severity of the injury and the extent of thoracic duct damage. Low-output chylothorax (<1000 mL/day) is typically managed conservatively, whereas high-output cases (>1–1.5 L/day) often require surgical or radiological intervention [4,37,75]. In extreme cases, chyle output exceeding 2000 mL/day has been reported [6,15,21,30]. Blunt chest trauma frequently results from RTA, underscoring the risks of high-speed collisions [5,22,32]. Falls are another common cause, accounting for approximately 45% of cases in a study of patients with multiple traumas [76]. In this review, RTA was found to be the leading cause of injury in 41 cases (59.42%), followed by falls in 16 cases (23.19%), trauma by heavy objects in 6 cases (8.70%), physical punishment or child abuse in three cases (4.34%) and fistfights in one case (1.45%). Bilateral chylothorax occurred in 27.54% of cases, higher than previously reported. Consistent with the literature, right-sided involvement (55.07%) was more common than left-sided involvement (17.39%). This finding contrasts with the observation of Kakamad et al., who reported no laterality difference, but is similar to the findings of Maldonado et al., who reported right-sided involvement in 67% of cases and left-sided involvement in 33% [71,74]. Chyle volume varied significantly, with 40.58% of cases producing >1000–2000 mL/day, while 10 cases (14.50%) exceeded 2000 mL/day. The timing of chyle onset in this review varied, with symptoms developing within two days in 40.58% of cases and within three days to a week in 31.88%. These align with the finding that chylothorax most commonly manifests within 2 to 7 days following blunt chest trauma due to gradual pleural accumulation from duct leakage [71]. However, delayed onset beyond one month, as observed in 4.34% of reviewed cases, is rare but documented in the literature, with an extreme case reported up to 20 years post-trauma [18]. The biochemical composition of chyle among the reviewed cases primarily consisted of lipids (40.57%), with smaller proportions of lipid-protein mixtures (11.59%) and lipid-inflammatory cell mixtures (7.24%). Complex mixtures, including lipids, proteins, sugars, inflammatory cells, and ions, were identified in 5.80% of cases. These findings are consistent with the established biochemical profile of chyle, which is rich in triglycerides (≥110 mg/dL) and lymphocytes [71]. As reported in the literature, immunoglobulins and protein levels ranging from 2.2 to 6 g/dL underscore the nutritional and immunological impact of chyle loss [1,8,32]. In the present review, chest X-rays revealed pleural effusion in 55.07% of cases, consistent with its status as the most common radiographic finding in chylothorax, typically presenting as a homogeneous opacity [2,4,32,71]. Rib fractures and lung or mediastinal or heart shift each were observed in 10.14% of cases, with lung opacification in 8.70% and pneumothorax, or hemothorax in 7.24%, aligning with literature that highlights the utility of chest X-rays in detecting associated traumatic injuries, such as rib fractures and pulmonary contusions [2,6,77]. CT scans in the reviewed cases showed pleural effusion in 33.33% of cases and rib fractures in 20.29%. The detection of pneumothorax, hemothorax, or hemopneumothorax in 13.04% of cases further emphasizes the role of CT in visualizing coexisting traumatic injuries with greater detail than X-rays [4,77]. The initial approach to managing chylothorax primarily involves conservative measures, including nil per os (nothing by mouth), total parenteral nutrition, and adherence to a low-fat diet. Pharmacological interventions, such as octreotide, may decrease lymphatic flow and facilitate the closure of the leak [10,14,21,23]. In chylothorax management, chest tube placement is commonly maintained until chyle drainage significantly decreases or resolves. The duration varies from a few days to several weeks, influenced by the effectiveness of conservative approaches [78]. In this review, the chest tube was in place for one week or less in 17.39% of patients, while 15.94% required chest tube placement for more than one week until two weeks. Another 18.84% needed chest tube placement for over two weeks to one month, and 5.80% had chest tube placement exceeding one month. In cases where conservative management proves ineffective, surgical intervention becomes imperative. Thoracic duct ligation remains the definitive surgical option and can be performed via open thoracotomy or minimally invasive approaches [79]. Based on the findings of this review, besides drainage, treatments for chylothorax included parenteral nutrition (50.72%), thoracic duct closure (39.13%), and dietary modifications, such as a medium-chain fatty acid or low-fat diet (34.78%). Octreotide was administered in 24.64% of cases. Thoracic duct closure was performed via thoracotomy in 31.88% of cases, Fr microcatheter with fluoroscopic/ ultrasound guidance in 2.90%, VATS or laparoscopy in 2.90%, and coiling and glue embolization in 1.45%. In 59.42% of cases, thoracic duct closure was not performed or was unnecessary. The limitations of this study include the inherent nature of the reviewed studies, which were exclusively case reports due to the rarity of the condition. Consequently, drawing conclusions based on statistical analyses was not feasible. Additionally, the small sample size and the non-standardized data reporting across the included reports may have introduced potential bias into the findings of this review. While every effort was made to include all relevant studies identified through the search using predefined keywords, there remains the possibility that some studies were inadvertently overlooked. Conclusion BCTC is rare and complex, underscored by the wide variability in patient demographics, clinical presentations, chylothorax onset, and management approaches. Given the challenges posed by limited evidence, the findings emphasize the need for early recognition and individualized management strategies. Declarations Conflicts of interest: The authors have no conflicts of interest to disclose. Ethical approval: Not applicable. Consent for participation: Not applicable. Consent for publication: Not applicable. Funding: The present study received no financial support. Acknowledgements: None to be declared. Authors' contributions: FHK and HOA: major contributors to the conception of the study, as well as the literature search for related studies, and manuscript writing. HKA, BJHA, and HMA: Literature review, critical revision of the manuscript, and processing of the tables. SHM, BeAA, SMA, MNH, SSA, YMM, KAN, SHK and BaAA: Data extraction, data organization, and critical revision. All authors have read and approved the final version of the manuscript. Use of AI: ChatGPT-3.5 was used to assist with language refinement and improve the overall clarity of the manuscript. All content was thoroughly reviewed and approved by the authors, who bear full responsibility for the final version. Data availability statement: Not applicable.