A rarity at the Memphis VAMC

CHYLOTHORAX

Rebecca Linstead

Lingual Lipase

LIPID DIGESTION/TRANSPORT

Gastric lipase

LIPID DIGESTION/TRANSPORT

Bile Acids

LIPID DIGESTION/TRANSPORT

Micelle formation

LIPID DIGESTION/TRANSPORT

Chylomicron formation

Entrance into lymphatic system through lacteals

Dumped into circulation via lymphatic

system

LIPID DIGESTION/TRANSPORT

Thoracic duct: dietary long chain fatty acids are transported to the circulatory system via the thoracic duct and lymphatic system

LIPID DIGESTION/TRANSPORT

Chylothorax: chyle leak into the pleural cavity Chyle: lymphatic fluid

containing fat, protein and electrolytes

Etiology of chyle leaks Congenital defect Postoperative complication Trauma to chest or abdomen Cirrhosis

Post-operative complication in 1-4% of surgeries

CHYLE LEAK

Depletion of lymphocytesSelenium deficiencyDeficiencies of fat-soluble vitaminsHyponatremia, hypokalemiaAcidosisProtein deficiencies

LAB ABNORMALITIES

Medical DrainagePharmacological treatment (Octreotide)Surgical repair

Nutrition Inconclusive evidence based on limited studies

Low fat or fat free oral diet (MCT?)Enteral nutrition with a specialized formulaParenteral nutrition with no oral intake

TREATMENT

PMHx: HTN, CAD, abdominal aortic aneurysm (AAA), vitamin D deficiency, GERD, dyslipidemia, DM

E.S – 65 Y/O WM

Admission Anthropometrics Ht: 70 inch Wt: 188 DBW: 149-183 %DBW: 103% Recent wt changes: stable

Diagnosed with non-small cell lung cancer (10/13) Underwent left thoracotomy and left lung resection (11/5)

Milky pleural fluid (11/8); chylothorax likely due to lymphatic obstruction as a result of lung cancer – TPN initiated

Left VATS/Thoracotomy (11/25) Right thoracotomy for thoracic duct ligation (12/2) Receiving radiation for NSCLC to decrease amount of pleural

drainageOther significant events during admission

Anemia requiring transfusion Septic shock Recurrent A-fib AKI (followed by nephrology)

E.S – SIGNIFICANT EVENTS

BUN

ABNORMAL LAB VALUES

Sodium

Hyponatremia 2/2 chronic SIADH

ABNORMAL LAB VALUES

ABNORMAL LAB VALUES

Creatinine

Serum Phosphorus

ABNORMAL LAB VALUES

Accuchecks during TPN

ABNORMAL LAB VALUES

Laxatives: Lactulose, senna, polyethylene

glycol Antiemetic/antinausea

Ondansetron, promethazine Treatment for A-fib

Digoxin, metoprolol Treatment for

hypothyroidism Levothyroxine

Antianxiety Clonazepam

Phosphate binder Sevelamer Carbonate

Anticoagulant Heparin

Vitamins/supplements Folic acid, magnesium

sulfate Antihypertensive

hydralazine Antacid

Pantoprazole Insulin

Sliding scale Aide in urination

Tamsulosin

MEDICATIONS

TPN initiated (11/10) Decrease in drainage

Formula adjusted multiple times High accuchecks Increasing BUN and

creatinine Increasing phosphorus

and magnesium PO with little intake – stil l

on parenteral (11/24) Continue PN; po intake

improving (11/29)

Clear liquid diet after R thoracotomy (12/3)

Regular diet started with Cracker Barrell PRN (12/5)

TPN discontinued (12/6) Ileus developed; NPO

(12/8) Transfer to Palliative –

progressed to DM Diet (12/10)

NUTRITIONAL TIMELINE FOR CHYLOTHORAX

Objective: Decrease production of chyle Replace fluid and electrolytes Maintain and/or replete nutrition status

Nutrition prescription: 2137-2466 kcal/d 68-86 g protein/d

Nutrition Diagnosis Inadequate oral food and beverage intake related to

chylothorax as evidenced by need for parenteral nutrition support (RESOLVED)

Biting/chewing difficulty related to poor dentition as evidenced by patient statements during interview and need for chopped diet (NEW)

DIETARY TREATMENT

Medical Poor

Thoracic drainage continues despite TPN, radiotherapy and thoracic duct ligation

Going home with hospice care Discharged 12/18 on Pleuravac

Cardiac Surgery Clinic 12/30

Nutrition Improve quality of life

PROGNOSIS

Smoke A, DeLegge MH. Chyle leaks: consensus on management? Nutr i t ion in Cl in ica l Pract ice. 2008; 23:529-532

McCray S, Parr ish CR. Nutr i t ional management of chyle leaks: an update. Pract ica l Gastroenterology . 2011; 12-32.

Nair SK,Petko M, Hayward MP. Aetio logy and management of chylothorax in adults. Eur J Cardiothorac Surg (2007) 32 (2) : 362-369

The Cardiothoracic Surgery Network. L igat ion of the thoracic duct for chylothorax. Avai lable at : http: / /www.ctsnet.org/sect ions/c l in ica l resources/ thorac ic /expert_tech-19. Accessib i l i ty ver ified December 14, 2013.

http: / /www.studyblue.com/notes/note/n/11-30-12-9am- lymphat ics /deck/4634000 Escott-Stump S. Nutr it ion and Diagnosis-Related Care. Ba lt imore, MD: Wi l l iams &

Wi lk ins; 1998. http: / /

2t ime.fi les.wordpress .com/2008/02/mouth-3d_model_anat_openmouth_web1. jpg http: / /www.sc iencealert .com.au/news/20121610-23799.html http: / /www.medindia .net/pat ients /pat ient info/sc leros ing-cholangi t is .htm http: / /www.ks .u iuc .edu/Gal lery /Sc ience/membrane_prote ins / tn /micel le . jpg.html http: / /d ietheartnews.com/2012/02/the-mighty-chylomicron-or-why-dr-robert-c-atk i

ns-was-r ight/

http : / /www.methuen.k12.ma.us /mnmelan /d igest ive%20system.htm

REFERENCES