Pam J Chyle Leak Presentation
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Transcript of Pam J Chyle Leak Presentation
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CHYLE LEAK Overview, Causes, Composition, Diagnosis, Complications, Maintenance,
Treatment, and ManagementReport by: Pamela Johnson
Sodexo Distance Dietetic Internship
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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
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Icebreaker
• Word Jumble!
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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
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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
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Digestion of Fat
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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)
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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
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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
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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
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Treatment Diagram
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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
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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
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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
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High Protein Consumption
• Chyle contains significant amounts of protein• 22-60g/L
• Recommend:
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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
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Treatment: Specialized Formula
• Output less than 1000 mL/day May indicate Enteral Formula
• Modified Enteral Regimen using Fat-Free Oral Supplement
• Parenteral Nutrition Indications
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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
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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
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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)
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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
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Questions?
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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.