Şilotoraks

Özet

Şilotoraks, torasik kanal veya lenfatik dallardan şilöz içeriğin plevral boşluğa kaçmasıdır; lenfoma ve diğer maligniteler, cerrahi ya da travma başlıca nedenler arasındadır. Toraks BT efüzyonu gösterir ve olası kitle, lenfadenopati, cerrahi alan ya da travmatik kanal hasarını araştırır; sıvının görünümü tek başına şilotoraksı doğrulamaz. Kaçağın kaynağı rutin BT'de seçilemeyebilir ve seçilmiş olgularda lenfatik görüntüleme gerekir. Süren kaybın fark edilmemesi beslenme ve bağışıklık sorunlarına katkıda bulunabilir; bu nedenle radyolojik neden araştırması önemlidir.

Faz ve pencere

Venöz

Kontrastlı toraks BT'de atenüasyonu özgül olmayan tek veya iki taraflı plevral efüzyonla birlikte mediastinal kitle/lenfadenopati, özofagus veya torasik kanal komşuluğundaki cerrahi-travma alanı ve eşlik eden tümör aranır; rutin faz çoğu kez kaçağı doğrudan göstermez.

Önerilen pencereler: Mediasten (G 350 / M 50), Akciğer (G 1500 / M -600).

BT bulguları

• Tek veya iki hemitoraksta serbest ya da loküle plevral sıvı; BT atenüasyonu şilöz içeriği tanımlamaz
• Posterior mediastende torasik kanal seyri ve özofagus çevresinde kitle, lenf nodu veya cerrahi klipsler
• Üst mediastinal ve supraklaviküler lenfadenopati; özellikle lenfoma açısından dağılımını haritalayın
• Özofagus cerrahisi ve diğer toraks girişimleri sonrası torasik kanal yaralanması gelişebilir; travma da kanalı zedeleyebilir.
• Eşlik eden akciğer kitleleri, plevral implantlar, mediastinal hastalık veya asit gibi altta yatan neden ipuçları
• Rutin kontrastlı BT'de görünmeyebilen torasik kanal kaçağı; klinik şüphe sürerse özel lenfatik görüntüleme gereksinimi

Normalde

Normal plevral boşlukta yalnız az miktarda fizyolojik sıvı bulunur; rutin BT’de belirgin efüzyon görülmez; torasik kanal posterior mediastende aorta ile azygos sistemi arasında ince yumuşak doku yapısı olarak ilerler ve çevre yağ planları açıktır. Efüzyonu ve kanalın seyri boyunca kitle/lenf nodu veya ameliyat alanını karşılaştırın; sıvının düşük ya da yüksek atenüasyonunu şilöz içeriğin kanıtı saymayın.

Ayırıcı tanı

Psödoşilotoraks

kronik inflamatuvar efüzyon ve kalın/kalsifiye plevra eşlik edebilir; BT, sıvı biyokimyası olmadan güvenilir ayırım yapmaz.

Malign plevral efüzyon

plevral nodüller veya kontrastlanan düzensiz plevra ile primer tümör lehine bulgular görülebilir.

Ampiyem

loküle efüzyon, kontrastlanan plevra kalınlaşması/enhancement'ı ve çevre yağ dokusu reaksiyonu ile karakterizedir.

Travma ilişkili şilotoraks kanlı veya serozanguinöz sıvı ile başvurabilir; ayırıcı tanı için sıvı biyokimyası ve sitoloji gereklidir.

Kalp yetmezliği, transüdatif plevral efüzyona yol açabilen ve nadiren şilotoraksla da ilişkili olabilen bir ayırıcı nedendir.

Tuzaklar

• Sıvı dansitesi veya süt renginde örnek tek başına tanı koydurmaz; şilomikron saptanması ya da plevra sıvısı lipid analizi gerekir.
• Açlık, malnütrisyon veya kanlı sıvı klasik görünümü değiştirebilir; seröz ya da kanlı efüzyon şilotoraksı dışlamaz.
• Rutin toraks BT'de kaçak odağı görülmemesi lenfatik yaralanmayı dışlamaz; gerektiğinde CT lenfanjiyografi, MR lenfanjiyografi veya lenfanjiyografi planlanır.

Kendini dene

1. Lenfoma tanılı hastada iki taraflı efüzyon var, ancak BT'de kaçak seçilmiyor. Şilotoraksı doğrulamak için ne gerekir?

   • Plevra sıvısı lipid analizi
   • Kontrastsız BT
   • Kemik sintigrafisi
   • Akciğer grafisi
   Cevabı göster

   Plevra sıvısı lipid analizi. BT neden olabilecek lenfomayı ve efüzyonu gösterebilir, ancak sıvı şilöz niteliğini kanıtlamaz. Plevra sıvısında şilomikron veya uygun lipid analizi tanısal doğrulamaya yardım eder.

2. Özofagus cerrahisi sonrası plevral efüzyon sürüyor; rutin BT'de kaçak görünmüyor. Hangi görüntüleme yaklaşımı kaçağı haritalayabilir?

   • Lenfatik görüntüleme
   • HRCT
   • BTPA
   • Kemik algoritması
   Cevabı göster

   Lenfatik görüntüleme. CT veya MR lenfanjiyografi ve seçilmiş durumda konvansiyonel lenfanjiyografi torasik kanal ve kaçak bölgesini değerlendirebilir. HRCT parankimi, BTPA pulmoner arterleri, kemik algoritması ise kemik yapıları hedefler.

Kaynaklar

Bu sayfadaki 34 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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