The survey says... chyle

We are back from a fast trip to Boston two weeks ago.  Tests seem to point that the fluid leaking out is chyle, and that it is limited to the fistula versus the entire bowel. We tested Peter with a 12 hour fast, which was easily accomplished overnight.  Since he is still on TPN 7 nights a week, it was even easier.  Then we collected his ileostomy and fistula outputs for testing.  After he woke up, we gave Peter 3 ounces of whole milk with olive oil in it, waited an hour and a half, and collected both outputs.  Then we gave him the same drink a second time, waited an hour and a half, and collected both outputs again.  The crazy part of the second collection is that due to the timing of collection, it needed to be done in a public restroom and then placed in a box with ice alongside of the other specimens, all the while trying to remain clean about the process, and quick, as we had already checked in to the waiting area to see the doctor.

The fistula output turned very cloudy after the fatty meals, suggesting chyle, and the fistula electrolytes suggest chyle.  The ileostomy had a lot of undigested sugars, which may be due to the fatty meal or due to his condition of short gut, or could be pancreatic insufficiency, so we are now testing the pancreatic enzymes in his ileostomy outputs.  Some questions arise as to why the chyle in the fistula is not high in protein, and why the ileostomy triglycerides were elevated after a fatty diet, but Peter's tests usually lend to results that need interpretation versus "going by the book."  So, with much discussion and interpretation, the impression is that it is a chyle leak in the intestine that is connected to the fistula, but that the rest of the GI tract seems to not have a chyle leak.  It is good news that the chyle leak seems to be isolated to the fistula.


Further good news of all of this is that it looks like surgery will be the answer to stopping the chyle leak.  No one wants to take Peter off all feeds for 4 to 6 weeks to attempt to have the leak close on its own, as his liver is already taxed on the amount of TPN he receives.  Feeding the gut helps to keep the liver happy, even if the feeds are small in amount.  We will actually try to increase feeds slowly, keeping to low fat, and then in several months hopefully surgically remove the fistula and the chylous intestine that is attached to it.  Details of course need to be hammered out and this plan is only in the beginnings of talk, but Peter did so well with the last surgery that it may be feasible to get rid of the fistula altogether despite the concerns that have come up about doing so in the past.  Our earlier talks for the next surgery were for a take-down of the ileostomy, so I don't know yet if the fistula surgery would take precedence over that or if they would be combined surgeries.