1. A rarity at the Memphis VAMC CHYLOTHORAX Rebecca Linstead

2.  Lingual Lipase LIPID DIGESTION/TRANSPORT

3.  Gastric lipase LIPID DIGESTION/TRANSPORT

4.  Bile Acids LIPID DIGESTION/TRANSPORT

5.  Micelle formation LIPID DIGESTION/TRANSPORT

6.  Chylomicron formation

7.  Entrance into lymphatic system through lacteals  Dumped into circulation via lymphatic system LIPID DIGESTION/TRANSPORT

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

9.  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 CHYLE LEAK

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

11.  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 TREATMENT

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

13.  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) E.S – SIGNIFICANT EVENTS

14.  BUN ABNORMAL LAB VALUES

15.  Sodium  Hyponatremia 2/2 chronic SIADH ABNORMAL LAB VALUES

16.  Creatinine

17.  Serum Phosphorus ABNORMAL LAB VALUES

18.  Accuchecks during TPN ABNORMAL LAB VALUES

19.  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 MEDICATIONS

20.  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) NUTRITIONAL TIMELINE FOR CHYLOTHORAX

21.  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) DIETARY TREATMENT

22.  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 PROGNOSIS

23.  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. 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.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-19  http://www.studyblue.com/notes/note/n/11-30-12-9am-lymphatics/deck/4634000 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://2time.files.wordpress.com/2008/02/mouth- 3d_model_anat_openmouth_web1.jpg  http://www.sciencealert.com.au/news/20121610-23799.html http://www.sciencealert.com.au/news/20121610-23799.html  http://www.medindia.net/patients/patientinfo/sclerosing-cholangitis.htm http://www.medindia.net/patients/patientinfo/sclerosing-cholangitis.htm  http://www.ks.uiuc.edu/Gallery/Science/membrane_proteins/tn/micelle.jpg.html 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://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 http://www.methuen.k12.ma.us/mnmelan/digestive%20system.htm REFERENCES