Case Study:

Chyle Leak
Kennedy Fitzgerald
Dietetic Intern and M.S. Candidate
Auburn University
 • Background
• Fat Digestion & Absorption
• Treatment
• Nutritional Management
Outline • Patient Profile
• ADIME
• Conclusion
• Acknowledgements
 • Chyle is a milky, odorless fluid consisting of lymph and
emulsified fat.1
• 200 kcal/L, 30 g/L of protein, 4-40 g/L of lipids
• Rare problem resulting from injury or abnormality of
thoracic duct
• May present as chylothorax or chylous effusion, chylous
Introduction: ascites, chylopericardium or as an external draining
fistula.1
Chyle Leak
Symptoms and Diagnosis:
• Dyspnea, coughing, chest discomfort and/or tachycardia3
• Proposed methods range from chest x-rays to CT scans
of thorax to assessing pleural fluid with respect to color,
composition, and volume
Treatment

• Management dependent on underlying cause

• Surgical Management
• >500 cc/day for 7 days while other suggest >1.5 L/day for longer than 5-7 days 5
• Remain largely clinician dependent
• Octreotide
• Reduced GI blood flow and hormone secretion
• Observational study, chyle leaks ceased by day 5 in patients who received continues
infusions 6
• Removal of fluid via percutaneous aspiration or drainage may be necessary to reduce
symptoms, while long term management is ongoing.6
Nutrition Management

• MNT is first line of defense in chyle leak management

• Success rate of 80% 6
• Goals of care are to: 1
1. Decrease production of chyle fluid
2. Replace fluid and electrolyte loss
3. Maintain or replete nutritional status and prevent malnutrition
• Diet types: 3,4,6
• Fat-free diet, Fat-free diet with MCT oil, EN, TPN
Patient: JC 83 yo Male

• PMH: arthritis, diverticulosis, HTN, stomach ulcers, kidney stones, SOB, chylous pleural
effusion
• PSH: colonoscopy, EGD, kidney stone basket extraction, lithotripsy, recurring
thoracenteses
• Presented in June with SOB and orthopnea
• Initial thoracentesis 6/8 with 2000 mL removed
• TG concentration of 1758 mg/dL
• PET-CT revealed a posterior mediastinal mass extending into the right and left paraspinal
region to the level of aortic hiatus
• Diagnosed with low-grade-B-cell lymphoma, most consistent with marginal zone
lymphoma
• Weekly therapeutic thoracenteses draining 2-3 L of chylous fluid each time
Nutrition Assessment

1. Initial Nutrition Consult (9/20): Nutrition Assessment

• JC reported a 15 lb weight loss since April due to taste changes and early satiety
• RD consulted reviewed foods to limit when experiencing early satiety and encourage
small frequent meals. RD provided MNT for taste changes- oral rinse before and after
eating, offset sweetness with bitter/tart flavors.

2. Second Nutrition Consult (10/4): Low-fat diet education/MCT oil supplementation

• 57.3 kg, BMI 21.6 kg/m2 (normal), IBW 59.1 kg
• All laboratory values WNL expect albumin 2.6 g/dL (-)
• RD provided low-fat diet education and fat-free ONS
Nutrition Diagnosis

• Altered GI function related to alterations in GI structure secondary to marginal

zone lymphoma as evidenced by a chylothorax, weekly thoracenteses, and a
consult for fat-free diet education.
• Estimated Nutrition Needs: Per WellStar Guidelines for cancer (losing weight),
BMI 18.5-25, > 60 yrs old.
• EEN: 1720-2290 kcals/day; 30-40 Kcal/kg actual BW
• EPN: 69-115 grams/day; 1.2-2.0 grams/kg actual BW
• EFN: 1 mL/ 1 kcal or per MD order
Nutrition Intervention

1. RD recommended implementation of a fat free/low fat diet to decrease production of

chyle fluid to promote healing of chylous leak.
2. Supplements: Boost Soothe (300 kcal and 10 g protein per serving), Ensure Clear (180
kcal and 8 g protein per serving) and/or Carnation Instant Breakfast with skim milk to
supplement calorie and protein needs; samples and coupons provided. RD will call pt’s
local grocery stores to make sure Ensure Clear is in supply.
3. RD recommended the use of a multivitamin due to risk of EFA and fat-soluble vitamin
deficiencies with fat free diet.
4. If weight loss continues, RD recommends trial of MCT oil as a lipid source because it
bypasses the lymphatic system.
Nutrition Monitoring/Evaluation

PO intake, weight trends, laboratory values, bowel function

Follow Ups:
• 10/6: Pt having difficulty finding fat-free ONS. RD provided list of retailers and website link
for online ordering.
• 10/8: Pt wife reported 900 mL of fluid removed on 10/8. Indicated that pt is adhering to
fat-free diet and ONS.
• 10/12: 2000 mL of fluid removed.
• 10/19: 2000 mL of fluid removed. RD spoke with pt over the phone who reported that his
weight is the same. Pt reported that he feels better. He does not like the Carnation
Breakfast but enjoys Ensure Clear and Boost Soothe.
Conclusion

• Chyle leaks are a complex problem resulting from injury or abnormality of thoracic
duct
• Serious complications including dehydration, malnutrition, and immunosuppression
• JC
• Low-grade-B-cell lymphoma
• Weekly thoracenteses removing 2-3 L of fluid
• Low-fat diet education, Fat-free ONS, Multivitamin, MCT oil is weight loss continues
• Future research to establish guidelines regarding optimal route, nutrient mix, and
duration of nutrition support needed to manage chyle leaks.
Acknowledgments

• Sarah S. Ludwick, MPH, RDN, LD, CDE, supervised the dietetic

intern.
• Amy Lloyd RD, LD, served as the lead dietitian for nutrition care
management, assisted with patient follow-up, and monitored
patient nutrition needs.
References

1. McCray S, Parrish CR. When Chyle Leaks: Nutrition Management Options. Pract. Gastroenterol. 2004;17, 60-
76. https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/McCray-may04.pdf. Accessed
October 5, 2021.
2. Smoke A, DeLegge MH. Chyle Leaks: Consensus on Management? Nutr Clin Pract. 2008;23(5), 529-532.
https://pubmed.ncbi.nlm.nih.gov/18849558/. Accessed October 5, 2021.
3. Kotze V, Van Schalkwyk N. Medical Nutrition Therapy for a Patient Presenting with a Chylothorax. S Afr J Clin
Nutr. 2013;26(3), 152-155. http://www.sajcn.co.za/index.php/SAJCN/article/view/809. Accessed October 5,
2021.
4. Sriram K, Meguid RA, Meguid MM. Nutritional Support in Adults with Chyle Leaks. Nutrition. 2016;32, 281-286.
https://www-sciencedirect-com.spot.lib.auburn.edu/science/article/pii/S0899900715003378?via%3Dihub.
Accessed October 5, 2021.
5. Karagiania J, Sheean PM. Managing Secondary Chylothorax: The Implications for Medical Nutrition Therapy. J
Am Diet Assoc. 2011;111(4), 600-604. https://jandonline.org/article/S0002-8223(11)00015-0/fulltext. Accessed
October 5, 2021.
References Cont.

6. Bibby AC, Maskell NA. Nutritional Management in Chyle Leaks and Chylous Effusions.
Br J Community Nurs. 2014;19(11), S6-8. https://pubmed.ncbi.nlm.nih.gov/25381927/.
Accessed October 5, 2021.
7. Kalomenidis I. Octreotide and Chylothorax. Curr Opin Pulm Med. 2006;12, 264- 267.
https://pubmed.ncbi.nlm.nih.gov/16825878/. Accessed October 10, 2021.
8. UVA Nutrition: GI Nutrition Support Team. Very Low-Fat Diet for Chyle Leaks.
https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2020/03/Chyle-
Leak-Diet-2-21-20.pdf. Accessed October 5, 2021.
9. St. Joseph’s Healthcare. Fat-Free Diet for a Chyle Leak.
https://www.stjoes.ca/patients-visitors/patient-education/a-e/ChyleLeakFatFreeDiet-
trh%20(2).pdf. Accessed October 5, 2021.