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Chylothorax

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.

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Chylothorax

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  1. Chylothorax A rarity at the Memphis VAMC Rebecca Linstead

  2. Lipid digestion/transport • Lingual Lipase

  3. Lipid digestion/transport • Gastric lipase

  4. Lipid digestion/transport • Bile Acids

  5. Lipid digestion/transport • Micelle formation

  6. Chylomicron formation

  7. Lipid digestion/transport • Entrance into lymphatic system through lacteals • Dumped into circulation via lymphatic system

  8. LIPID DIGESTION/TRANSPORT Thoracic duct: dietary long chain fatty acids are transported to the circulatory system via the thoracic duct and lymphatic system

  9. 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

  10. Lab abnormalities • Depletion of lymphocytes • Selenium deficiency • Deficiencies of fat-soluble vitamins • Hyponatremia, hypokalemia • Acidosis • Protein deficiencies

  11. 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

  12. 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

  13. 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)

  14. Abnormal Lab values • BUN

  15. Abnormal lab values • Sodium • Hyponatremia 2/2 chronic SIADH

  16. Abnormal lab values • Creatinine

  17. Abnormal lab values • Serum Phosphorus

  18. Abnormal lab values • Accuchecks during TPN

  19. Medications • Vitamins/supplements • Folic acid, magnesium sulfate • Antihypertensive • hydralazine • Antacid • Pantoprazole • Insulin • Sliding scale • Aide in urination • Tamsulosin • 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

  20. Nutritional timeline for chylothorax • 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) • 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)

  21. 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)

  22. 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

  23. references • Smoke A, DeLegge MH. Chyle leaks: consensus on management? Nutrition in Clinical Practice. 2008; 23:529-532 • McCray S, Parrish CR. Nutritional management of chyle leaks: an update. Practical Gastroenterology. 2011; 12-32. • Nair SK,Petko M, Hayward MP. Aetiologyand management of chylothorax in adults. EurJ CardiothoracSurg(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/11-30-12-9am-lymphatics/deck/4634000 • Escott-Stump S. Nutrition and Diagnosis-Related Care. Baltimore, MD: Williams & Wilkins; 1998. • http://2time.files.wordpress.com/2008/02/mouth-3d_model_anat_openmouth_web1.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-c-atkins-was-right/ • http://www.methuen.k12.ma.us/mnmelan/digestive%20system.htm

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