pam j chyle leak presentation

CHYLE LEAK Overview, Causes, Composition, Diagnosis, Complications, Maintenance,

Treatment, and ManagementReport by: Pamela Johnson

Sodexo Distance Dietetic Internship

Why Chyle Leaks?

• “Hot Topic” during my time as a Dietetic Intern at Sharp Grossmont Hospital (3 Individual Cases)

• Typically very rare case that not many interns may be able to learn about

• New and interesting topic for myself to learn about during my internship

Icebreaker

• Word Jumble!

What is Chyle?

• Milky like-fluid consisting of lymph and chylomicrons made in the small intestine during the digestion of fat and drained by lacteals into the lymphatic system • Made up of lipids, protein, electrolytes, and cellular elements• Odorless and Alkaline • 1 liter Contains roughly:

• 200 Calories• 20-30g Protein• 5-30g Fat

Lymphatic System

Functions of the lymphatic system:1. Immunological Role2. Absorption of excess

interstitial fluid and its return to the bloodstream

3. Transport of long chain fat and fat-soluble vitamins

Lymph System Includes:• Lymph vessels and

capillaries• Thoracic duct• Lymph nodes• Spleen• Thymus• Bone marrow and gut

associated lymphoid tissues

Digestion of Fat

What are the potential causes?

• Primary: Congenital Lymphangiectasia

• Secondary: Postoperative trauma or obstruction following abdominal, neck or thoracic operations • Abdominal aortic surgery, lymph node dissection, duodeno-

pancreatic resections, esophageal procedures, thoracic and cervical spine procedures, and left neck dissections

• Incidence rate of 1-4%

• Non-Traumatic Causes such as cancer of the lymphatic system (lymphoma)

Complications due to a Chyle Leak

• Damage due to compression• Depletion of lymphocytes• Impaired cell immunity leading to immunosuppression• Loss of bacteriostatic agents more at risk for bacterial

infection• Nutrition Related Complications/Concerns

• Malnutritionloss of calories, protein, and fat soluble vitamins• Hypovolemialoss of fluid and electrolytes

Symptoms Associated with a Leak

• White or reddish milky fluid drainage from drains in the chest, abdomen, or neck • Pleural Fluid Trigcylgeride level greater than 110 mg/dL• Dyspnea, chest pain, and tachycardia• Pleural effusion and abdominal ascites

Treatment Options

• Vary patient by patient depending on patient’s needs

• Options Include:• Dietary Modification • Specialized low-fat formula for Enteral Nutrition for those who cannot

tolerate an oral diet • Bowel rest with parenteral nutrition for those with a non-functioning GI

tract• Pharmacological (Octreotide) • Drainage • Direct Surgical Repair

Treatment Diagram

Treatment: Oral Dietary Modification

• Goal: Decrease production of flow, replenish fluid and electrolyte loss, and prevent malnutrition by the repletion of nutrition stores

• Low-Fat or Fat-Free Diet

• MCT Oil Supplementation

Low-Fat/Fat-Free Diet

• Aim for < 10-20g Fat per day• Read food labels Ex: Choose items with <0.5 g of fat per

serving

Complications: Essential Fatty Acid Deficiency

• Restricted diet in the form of Low-Fat or Fat-Free• Body cannot receive adequate essential fatty acids via oral diet • Can occur within 2-4 weeks • Symptoms of EFAD associated with chyle leak

• Eczema, impaired wound healing, thrombocytopenia (blood platelet deficiency)

• Intravenous Lipid Emulsions (IVLE) • Provide source of EFA • Delivered directly into bloodstream and do not pass through the lymphatic system

High Protein Consumption

• Chyle contains significant amounts of protein• 22-60g/L

• Recommend:

Medium Chain Triglyceride Oil

• Special kind of fat the body can absorb by bypassing the lymphatic system• MCT rapidly absorbed binding with albumin and

transported directly to the liver via portal vein • Will not cause chyle build up

Treatment: Specialized Formula

• Output less than 1000 mL/day May indicate Enteral Formula

• Modified Enteral Regimen using Fat-Free Oral Supplement

• Parenteral Nutrition Indications

Treatment: Pharmacological

• Octreotide• Somatostatin Analog• Inhibits growth hormones, glucagon, insulin, and suppresses GI

hormones• Works by decreasing lymph flow and intestinal absorption of fats • Typically 50 micrograms 3 x day • Side Effects: nausea, diarrhea, cutaneous flushing, sinus

bradycardia, and elevated liver function

Treatment: Surgical Repair

• Indications:• >1L output present • No signs of closure within 2-3 weeks• Signs of nutritional or metabolic complications from leak • Further damage is present • Patient begins to deteriorate

Possibilities Requiring Evidence Based Research

• Recommend a High-Fat diet 1 day prior to surgery/procedure?

• Is a Clear Liquid Diet post-op appropriate?

• Liberalizing fat intake within an oral diet based on chyle output?

• Micronutrient loss (Selenium Deficiency)

Conclusion

• Treatment varies depending on the patient and patient’s needs

• Nutrition therapy and management is an important component in chyle leak treatment

• Very important to evaluate individuals thoroughly in order to determine the best and most successful type of regimen

Questions?

References

• McCray, Stacey, and Carol Rees Parrish. "Nutritional management of chyle leaks: an update." Pract Gastroenterol 94 (2011): 12-32.

• Qureshi, Sajid S., et al. "Chyle leak following surgery for abdominal neuroblastoma." Journal of pediatric surgery (2015).

• Sriram, Krishnan, Robert A. Meguid, and Michael M. Meguid. "Nutritional support in adults with chyle leaks." Nutrition (2015).

• Smoke, Addy, and Mark H. DeLegge. "Chyle leaks: consensus on management?." Nutrition in Clinical Practice 23.5 (2008): 529-532.