CHYLOTHORAX A rarity at the Memphis VAMC Rebecca

CHYLOTHORAX A rarity at the Memphis VAMC Rebecca Linstead

LIPID DIGESTION/TRANSPORT Lingual Lipase

LIPID DIGESTION/TRANSPORT Gastric lipase

LIPID DIGESTION/TRANSPORT Bile Acids

LIPID DIGESTION/TRANSPORT Micelle formation

Chylomicron formation

LIPID DIGESTION/TRANSPORT 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

CHYLE LEAK 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

LAB ABNORMALITIES Depletion of lymphocytes Selenium deficiency Deficiencies of fat-soluble vitamins Hyponatremia, hypokalemia Acidosis Protein deficiencies

TREATMENT Medical § Drainage § Pharmacological treatment (Octreotide) § Surgical repair Nutrition § Inconclusive evidence based on limited studies § Low fat or fat free oral diet (MCT? ) § Enteral nutrition with a specialized formula § Parenteral nutrition with no oral intake

E. S – 65 Y/O WM PMHx: HTN, CAD, abdominal aortic aneurysm (AAA), vitamin D deficiency, GERD, dyslipidemia, DM Admission Anthropometrics § § § Ht: 70 inch Wt: 188 DBW: 149 -183 %DBW: 103% Recent wt changes: stable

E. S – SIGNIFICANT EVENTS 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 drainage Other significant events during admission § § Anemia requiring transfusion Septic shock Recurrent A-fib AKI (followed by nephrology)

ABNORMAL LAB VALUES BUN

ABNORMAL LAB VALUES Sodium Hyponatremia 2/2 chronic SIADH

ABNORMAL LAB VALUES Creatinine

ABNORMAL LAB VALUES Serum Phosphorus

ABNORMAL LAB VALUES Accuchecks during TPN

MEDICATIONS 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

NUTRITIONAL TIMELINE FOR CHYLOTHORAX 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 – still on parenteral (11/24) Continue PN; po intake improving (11/29) Clear liquid diet after R thoracotom y (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)

DIETARY TREATMENT 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)

PROGNOSIS 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

REFERENCES Smoke A, De. Legge MH. Chyle leaks: consensus on management? Nutrition in Clinical Practice. 2008; 23: 529 -532 Mc. Cray S, Parrish CR. Nutritional management of chyle leaks: an update. Practical Gastroenterology. 2011; 12 -32. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg (2007) 32 (2): 362 -369 The Cardiothoracic Surgery Network. Ligation of the thoracic duct for chylothorax. Available at: http: //www. ctsnet. org/sections/clinicalresources/thoracic/expert_tech-19. Accessibility verified December 14, 2013. http: //www. studyblue. com/notes/note/n/11 -30 -12 -9 am-lymphatics/deck/4634000 Escott-Stump S. Nutrition and Diagnosis-Related Care. Baltimore, MD: Williams & Wilkins; 1998. http: //2 time. files. wordpress. com/2008/02/mouth 3 d_model_anat_openmouth_web 1. jpg http: //www. sciencealert. com. au/news/20121610 -23799. html http: //www. medindia. net/patients/patientinfo/sclerosing-cholangitis. htm http: //www. ks. uiuc. edu/Gallery/Science/membrane_proteins/tn/micelle. jpg. html http: //dietheartnews. com/2012/02/the-mighty-chylomicron-or-why-dr-robert-catkins-was-right/ http: //www. methuen. k 12. ma. us/mnmelan/digestive%20 system. htm