The Chyle Leak
Nutritional Implications,
Management, and a
Nutrition Care Case Study
Erin Lastnik
Dietetic Intern
Sodexo Mid-Atlantic Dietetic Internship
February 1, 2013
Objectives
Identify two nutritional implications of a
chyle leak.
 Explain the role of chyle in fat absorption.
 Identify three nutritional interventions for
a chyle leak.

Introduction
IH is a 62 year old female
 African American
 Graduated high school, married with six
children, retired
 Admitted to St. Joseph’s on 11/24/12

Medical Background

Past Medical History
◦ Type 2 diabetes, CVA x2, CAD s/p CABG x4,
HTN, anemia, CKD Stage 3, one C-section,
hysterectomy

CABG x4 was at St. Joseph’s on 10/29/12
◦ Rehabilitation center for three weeks
 Left pleural effusion
 Three admissions for thoracentesis
Admission 11/24/12

IH admitted with SOB, chest discomfort
◦ Dx: Pleural Effusion

Physical
◦ Reduced muscle strength, slow speech, trace
edema

Medications PTA
◦ Aspirin, Colace, Doxycycline, Levemir,
Lexapro, Plavix, Simvastatin, Toprol XL,
Oxycodone, Reglan

Labs WNL
◦ Albumin 2.6 g/dL; Creatinine 1.2 mg/dL
Initial Findings

Chest x-ray and thoracentesis with fluid
analysis
◦ Bilateral chylothorax
Definitions

Chyle
◦ White, milky fluid
containing
triglycerides,
protein,
lymphocytes and
electrolytes

Chylothorax
◦ Collection of chyle
and lymphatic fuid
in the pleural cavity
Anatomy and Digestion

Thoracic duct
◦ Cysterna chyli

Long-chain Triglycerides (LCT)
◦ Enzymes
◦ Micelle  Re-esterification  Chylomicron

Short chain/Medium chain Triglycerides
(SCT/MCT)
◦ No micelle or chylomicron
◦ Mucosa  Portal vein
◦ Evidence in lymphatic system
Etiology and Pathology

Primary Etiologies
◦ Congenital, obstruction, lymphagiectasis

Secondary
◦ Head/neck, thoracic, pancreatic, esophagus sx
Hours to months before identified
 Chylothorax, chylous ascites,
chylopericardium
 Dx

◦ TG >100 mg/dL
◦ TG 50-100 mg/dL requires chylomicrons
Nutritional Implications

Hypovolemia
◦ Hypokalemia, hyponatremia, hypocalcemia

Protein loss
◦ Hypoalbuminemia

Malabsorption
◦ Caloric, vitamins, medications

Immunosuppression
Management of a Chyle Leak
Conservative Interventions

Very low fat diet
◦ <10 - <20 g/day
 Caloric loss of fat: MCT oil/elemental formula
 MCT oil does NOT prevent EFAD

Enteral Nutrition (EN)
◦ Elemental/Semi-elemental formula
 Peptamen®

Total Parenteral Nutrition (TPN)
◦ Chyle flow
◦ Bowel rest
◦ Bowel atrophy/infection
Surgical Interventions
Persistent leaks: >500 mL/day for two
weeks
 Thoracic duct ligation
 Thoracic duct embolization
 Fibrin glue

Treatment and Hospital Course
Initial Visit 11/26/12: Assessment


Thoracentesis
Poor appetite PTA
◦ Felt it was increasing
◦ “Picky eater”
◦ Nausea

Reported weight loss
◦ Unsure of how much
◦ ~10# per computer records


Labs: BUN, Creatinine, Glucose
Estimated needs
◦ 1425 – 1600 kcal (25 – 28 kcal)
◦ 57 – 74 g protein (1 – 1.3 g/kg)
Initial Visit: Diagnosis

Suspected Suboptimal PO intake R/T
Poor appetite and nausea AEB pt
consuming 0 – 25% per computer records
Initial Visit: Interventions

Meals and Snacks
◦ Recommend continue current diet (Moderate
Consistent CHO), consider liberalizing to
Regular if PO intake <50%

Medical Food Supplement
◦ Recommend Resource Health Shake SF TID
with meals (600 kcal, 24 g protein)

Goal: PO intake >50%
Initial Visit: Monitor/Evaluate
PO intake
 Labs
 GI Status
 Weight

Follow-up 11/29/12: Assessment

Fluid analysis revealed bilateral
chylothorax
◦ Bilateral pigtail catheters

OR 12/3/12
◦ Thorascopic decortication with bronchoscopy
“Zero Fat” diet with Health Shakes
 Grand-daughter present during interview
to confirm poor PO intake
 Estimated needs

◦ 1425 – 1600 kcal (25 – 28 kcal)
◦ 74 – 103 g protein (1.3 – 1.8 g/kg)
First Follow up: Diagnosis

Suspected Suboptimal PO intake –
ongoing

Suspected Suboptimal PO intake –
confirmed
◦ Inadequate Oral Intake R/T Nausea and
decreased appetite AEB 0% of meals per
computer records and family member
◦ Altered GI Function R/T Change in accessory
organ function AEB Fluid analysis revealed
chyle leak
First Follow-up: Interventions

Meals and Snacks
◦ Recommend 20 g Low Fat diet

Medical Food Supplement
◦ Recommend change supplement to Resource
Breeze TID due to zero-fat content (750 kcal, 27
g protein)

Enteral Nutrition (EN)
◦ Recommend Vital AF 1.2 @ 55 mL/hr (1584 kcal,
99 g protein)

Parenteral Nutrition (PN)
◦ Recommend Standard PPN (1540 kcal, 100 g
CHO, 100 g protein, 80 g lipid)
First Follow-up: Monitor/Evaluate
Plan of care
 PO Intake
 GI Status
 Weight
 I&Os

Second Follow-up 11/30/12: Assessment
PPN initiated night of 11/29/12
 Central line plan
 Remained on “Zero Fat” diet

◦ PO intake was still 0%
◦ Resource Breeze ordered
Second Follow-up: Diagnosis

Suboptimal Oral Intake – ongoing
Second Follow-up: Interventions

PN
◦ If TPN initiated, recommend initiate at




Amino Acids 15% 550 mL = 75 g protein
Dextrose 70% 250 mL = 175 g dextrose
Lipid 20% 200 mL = 20 g lipid
Provides 1295 kcal
◦ Replete electrolytes PRN, pt is a refeeding
syndrome risk

Meals and Snacks
◦ Recommend continue “Zero Fat” diet per MD
Second Follow-up: Monitor/Evaluate
PO intake
 Labs
 GI Status
 Weight
 Plan of care

Follow-ups: 12/1, 12/4, 12/5, 12/7, 12/10, 12/13

PPN 11/29
◦ K+ drop 4.1 – 3.8

TPN 12/4 (POD #1)
◦ K + drop 3.8 – 3.6


NPO post TPN initiation
Elevated BG levels
◦ 10 units insulin in TPN bag; 50 units Lantus



Prealbumin: 11 mg/dL
Triglycerides: 64 mg/dL
Hypocalcemia
◦ 8.7, 8.4, 8.2, 8, 7.8 mg/dL
Follow-ups 12/1 – 12/13 Continued

Recommendations
◦ Increase Amino Acids to 570 mL = 85 g
◦ Increase Amino Acids to 600 mL = 90 g
(taken)

Routine chest scans
◦ Decreased chyle accumulation
◦ Chylopericardium

OR 12/12
◦ Pericardiocentesis with pericardial drain
◦ PleurX catheter
Follow-ups 12/15, 12/18, 12/19

Decreased drainage output; leak resolved?
◦ TPN stopped
◦ Regular diet ordered
◦ Bilateral pigtails removed

Calorie Count
◦ 0%; 1 meal = 275 kcal, 11 g protein

IH not meeting needs
◦ Recommendation for Glucerna 1.2 @ 55
mL/hr (1584 kcal, 79 g protein)
◦ Recommend reinitiate TPN at previous rate
Follow-ups 12/20, 12/21, 12/24, 12/28

IH began to eat and had increased drainage
◦ TPN recommended to PA

TPN reinitiated on 12/21 with previous
formula
◦ TPN x3 weeks
◦ NPO
Prealbumin: 13 mg/dL; 16 mg/dL
 Triglycerides: 141 mg/dL
 BG >200 mg/dL

◦ 20  45  65 units of insulin in TPN bage
Discharge

IH discharged on 1/2/13
◦ Dx: Chylothorax
TPN x3 weeks
 NPO
 PleurX catheter
 Pericardial drain removed

Questions?
References
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Bonner GM, Warren JM. A Review of the Nutritional Management of Chyle Leakage in Adults. Journal of Human Nutrition
and Dietetics. 1998 (11) 105-114.
Fahimi H, Casselman FP, Mariani MA, van Boven WJ, Knaepen PJ, van Swieten HA. Current Management of Postoperative
Chylothorax. Ann Thorac Surg 2001;71:448-450.
Gottschlich MM. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall Hunt Pub
Co; 2000; 481 – 485.
Hakim NS, Papalois VE. Surgical Complications: Diagnosis and Treatment. London, England: Imperial College Press; 2007; 222 –
225.
Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural Fluid Characteristics of Chylothorax. Mayo Clin
Proc. 2009;84:129–133.
McCray S, Parrish CR. When Chyle Leaks: Nutrition Intervention. Practical Gastroenterology 2011; 94; 12 – 22.
McGrath EE, Blades Z, Anderson PB. Department of Respiratory Medicine, Northern General Hospital, UK. Chylothorax:
Aetiology, Diagnosis and Therapeutic Options. http://www.pneumonologia.gr/articlefiles/chylothorax.pdf. Accessed 16 January
2013.
Nyquist GG, Hagr A, Sobol SE, Hier MP, Black MJ. Octreotide in the Medical Management of Chyle Fistula. Otolaryngology–
Head and Neck Surgery; 128, 6; 910 – 911.
Pakula AM, Phillips W, Skinner RA. A Case of a Traumatic Chyle Leak Following an Acute Thoracic Spine Injury: Successful
Resolution with Strict Dietary Manipulation. World Journal of Emergency Surgery 2011, 6:10.
Scholz GA, Sirbu H, Semrau S,Anders K, Mackensen A, Spriewald BM. Persisting Right-sided Chylothorax in a Patient with
Chronic Lymphocytic Leukemia: A Case Report. J Med Case Reports. 2011; 5: 492.
Skouras V, KalomenidisI. Chylothorax: Diagnostic Approach. Curr Opin Pulm Med. 2010 Jul;16(4):387-93.
Smoke A, DeLegge MH. Chyle Leaks: Consensus on Management?. Nutr Clin Pract. 2008; 23 (5): 529-532
Talwar A. Division of Pulmonary & Critical care medicine North-Shore University Hospital, Manhasset, NY. Chylothorax:
Recent Advances. http://lungtherapeutics.com/appDocs/Chylothorax-web%20site.pdf. Accessed 17 January 2013.
Timoney M. Department of Surgery SUNY Downstate/Kings County Hospital Center. Management of Chylothorax.
http://www.downstatesurgery.org/files/cases/Cyhlothorax.pdf. Accessed 16 January 2013.
Wakefield SC. ESPEN Congress. Specialized Oral or Enteral Nutrition Measures in Patients with Chyle Leaks.
http://www.espen.org/presfile/Wakefield_2012.pdf. Accessed 17 January 2013.