Serum cholesterol is measured to determine the concentration of circulating lipoprotein particles when screening for cardiovascular disease. The concentration is affected by genetic and lifestyle factors. Cholesterol concentrations in serous effusions increase due to exudative processes that cause cell lysis or increased vascular permeability. Measurement of cholesterol in body fluids is used for the diagnosis of a cholesterol effusion or cholesterol-rich pseudochylous effusion. Pseudochylous effusions contain low triglycerides and high cholesterol and occur from chronic pleural effusions such as rheumatic pleurisy and tuberculosis. Malignant effusions may become enriched with cholesterol due to increased synthesis and release from neoplastic cells or lymphatic obstruction.

Pleural fluid:

Chylothorax is the name given to pleural effusions containing chylomicrons with accordingly high triglyceride and low cholesterol concentrations, which occurs when chyle accumulates from a disruption of the thoracic duct caused mainly by malignancy or trauma.

Pseudochylous effusions accumulate gradually through the breakdown of cellular lipids in long-standing effusions such as rheumatoid pleuritis, tuberculosis, or myxedema, and by definition, the effluent contains high concentrations of cholesterol, while chylous effusions contain high concentrations of triglycerides in the form of chylomicrons.

Differentiation of pseudochylothorax from chylothorax is important as their milky or opalescent appearance is similar; however, therapeutic management strategies differ.

Measurement of pleural fluid cholesterol has also been investigated in multiple studies for the purpose of differentiating exudates from transudates. Most of these studies concluded that cholesterol performs as well as the measurement of lactate dehydrogenase and total protein applying Light’s criteria, but does not add much value beyond that.

Peritoneal fluid:

Ascites is the pathologic accumulation of excess fluid in the peritoneal cavity. Cholesterol analysis in the peritoneal fluid may be a useful index to separate malignant ascites from nonmalignant, often cirrhotic ascites. Studies report concentrations ranging from greater than 32 to 70 mg/dL are greater than 88% sensitive and greater than 80% specific for malignant ascites, outperforming cytology.