traumatic chylothorax
Introduction
Introduction to traumatic chylothorax The chylothorax is caused by rupture or obstruction of the thoracic duct for different reasons, causing the chyle to overflow into the chest cavity. The thoracic duct is the largest lymphatic vessel in the body and has a total length of about 30 to 40 cm. It originates from the chyle pool in front of the first lumbar vertebrae in the abdominal cavity, and passes through the aortic sulcus through the diaphragm and into the mediastinum. Then along the right front of the vertebral body and the posterior esophagus, the vertebral body is obliquely left to the left at the fifth thoracic vertebra. In the vertebral body and esophagus to the left side of the neck, through the carotid sheath behind the subclavian artery back and the left venous angle (the left jugular vein and the left subclavian vein confluence). basic knowledge The proportion of illness: 0.003% Susceptible people: no special people Mode of infection: non-infectious Complications: dehydration, electrolyte imbalance
Cause
Traumatic chylothorax
Traumatic (35%):
Chest trauma or intrathoracic surgery such as the esophagus, aorta, mediastinum or cardiac surgery may cause damage to the thoracic duct or its branches, allowing the chyle to spill into the pleural cavity, and sometimes excessive stretching of the spine may also cause damage to the thoracic duct.
Obstructive (25%):
Intrathoracic tumors such as lymphosarcoma, lung cancer or esophageal cancer compression intubation of the thoracic duct, obstruction of the proximal end of the thoracic duct due to excessive expansion, increased pressure, rupture of the thoracic duct or its collateral system, lumps caused by filariasis Very rare.
Other (5%):
Other causes of chylothorax are rare, congenital abnormalities of the mediastinum or pulmonary lymphatic vessels, occasionally seen in neonatal chylothorax cases, very few cases of cirrhosis and portal hypertension, due to thrombosis or other causes of upper body venous obstruction or lung Lymphoid hemangioma causes exudation of the subpleural lymph fluid, which may result in one or both sides of the chylothorax.
Under normal circumstances, except for the right upper limb and head and neck, the lymph fluid of the whole body is input into the thoracic duct, and then the left internal neck and the left subclavian vein are injected into the left neck to flow into the body vein system. From the 12th thoracic vertebra and the 2nd lumbar intervertebral sacral sac, along the abdominal aorta, in the right posterior aspect of the abdominal aorta, through the diaphragmatic aortic sulcus into the mediastinum, in the posterior mediastinal thoracic duct along the descending aorta Increased to the 5th and 6th thoracic vertebrae to the left side, and along the descending aorta and esophagus, and finally to the posterior aspect of the left subclavian artery to reach the neck and into the body vein, in view of the above-mentioned thoracic catheter anatomy The characteristics of the thoracic duct injury or obstruction located below the sixth thoracic vertebra (or below the abrupt vein level) often cause the right chylothorax, while the thoracic duct injury or obstruction above the fifth thoracic vertebra (above the aortic arch) often causes the left chylothorax .
Prevention
Traumatic chylothorax prevention
For the prevention of this disease, it is mainly to avoid chest trauma, preventive measures during thoracic surgery, try to avoid damage to the thoracic duct or its branches, and patients with pleural effusion for chest trauma, if necessary, carry out the IH-Sultan experiment .
Complication
Traumatic chylothorax complications Complications dehydration electrolyte disorder
Although chyle can inhibit bacterial growth, there are still individual patients with chylothorax and pleural infection, which can be life-threatening.
From the pathological point of occurrence of chylothorax, there are two cases of complications caused by chylothorax:
(1) When the nutrient-rich chylorrhea is lost in a large amount, it will inevitably cause severe dehydration of the body, electrolyte imbalance, dystrophic dysfunction and loss of a large amount of antibodies and lymphocytes, which reduces the body's resistance.
(2) The accumulation of a large amount of chyle in the pleural cavity will inevitably lead to the compression of the lung tissue, the mediastinal shift to the contralateral side and the large veins of the returning blood flow are partially obstructed, and the blood flow is not smooth, further aggravating the deficiency of systemic blood volume. And cardiopulmonary failure.
Symptom
Traumatic chylothorax symptoms Common symptoms Difficulty breathing, poor blood flow, rapid pacing, chest heart rate, fatigue, malnutrition, dizziness, chest tightness, low blood pressure
Traumatic thoracic duct injury has early symptoms, and is easily misdiagnosed as hemothorax in the early stage. After controlling bleeding, the thoracic drainage fluid changes from clear to turbid, from pale red to milky white, and with the increase of food intake (especially high fat food) Increased, the patient showed severe dehydration, weight loss and other symptoms of malnutrition, increased intrathoracic chyle accumulation increased pressure on the lung tissue, mediastinal shift to the contralateral side, return to the great venous return, patients with chest tightness, shortness of breath and difficulty breathing Such symptoms, decreased circulating blood volume and poor blood flow to the heart and vein, resulting in decreased cardiac output, increased heart rate, low blood pressure, patients complained of palpitations, shortness of breath, dizziness and fatigue, chyle can inhibit bacterial growth Therefore, chylothorax with pleural cavity infection is relatively rare.
The chylothorax contains more fatty substances than plasma, abundant lymphocytes and a considerable amount of protein, sugar, enzymes and electrolytes. Once the thoracic duct is ruptured, a large amount of chylomicron is extravasated into the pleural cavity, which will inevitably cause two serious consequences: First, the loss of nutrient-rich chylorrhea will inevitably lead to severe dehydration of the body, electrolyte imbalance, nutritional disorders and the loss of a large number of antibodies and lymphocytes, reducing the body's resistance; second, the accumulation of a large amount of chyle in the pleural cavity Inevitably, the lung tissue is compressed, the mediastinum is displaced to the contralateral side, and the large vein of the returning blood flow is partially obstructed, and the blood flow is not smooth, which further aggravates the deficiency of systemic blood volume and cardiopulmonary failure.
The amount of chyle infiltration into the pleural cavity varies from 100 to 200 ml per day, and up to 3000 to 4000 ml per day. This is mainly determined by the size of the thoracotomy, the negative pressure in the pleural cavity, and the amount of intravenous fluid. And its speed and the nature of the food intake.
Examine
Traumatic chylothorax examination
1. The following three methods can be applied to the examination of the amount of pleural effusion:
(1) X-ray inspection.
(2) Thoracentesis.
(3) chest drainage.
2, pleural fluid examination
If there is a typical external milk sputum, milky white, tasteless, not easy to coagulate, after being placed into 3 layers, the upper layer is a yellow creamy fat layer, can be clarified by adding ether, or Sudan III staining to find fat droplets, cell count to lymphocytes Mainly, the diagnosis of chylothorax can be established.
However, due to the long period of fasting after surgery, especially after esophageal cancer surgery, the pleural fluid is not a typical chyle; it usually begins with a bloody clear pleural fluid, which later turns into an orange-yellow plasma-like fluid, early chest. The positive rate of liquid for Sudan III staining test is not high, only about 50%. At this time, milk can be injected into the duodenal tube and butter. If the pleural fluid becomes milky white, the Sudan III staining is positive, and the diagnosis can be confirmed. At the same time, the pleural fluid and blood lipid test, if the content of cholesterol and triglyceride in the pleural fluid significantly exceeds the blood content, can also help to establish the diagnosis of chyle.
In some pleural infections and neoplastic diseases, a large amount of turbid chyle-like pleural effusion, pseudo-chyle sputum, pseudo-chyle pleural effusion containing lecithin protein complex, milky appearance, mainly by cell degeneration Decomposed, but the cell denaturing material has a low fat content, Sudan III staining negative, specific gravity <1.012, there are a lot of cells in this pleural sediment, but the lymphocytes are less, the protein and cholesterol levels are lower than the real chyle, Some tuberculous pleurisy, pleural effusion of cholesterol pleurisy is also easy to be confused with chyle, but the fat content is low, can be identified by Sudan III staining, and it is rare after trauma and surgery.
Diagnosis
Diagnosis and diagnosis of traumatic chylothorax
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Differential diagnosis
(1) Early attention should be paid to the identification of hemothorax. The chest X-ray manifestations of the disease and the performance of hemothorax and other effusions are all increased in density. The main point of differentiation is that there is a chyle-like change in the effusion, and the chyle test, ie, Yihong The Sudanese experiment can confirm the diagnosis.
(2) For the clinical symptoms with slow chylothorax, that is, the rupture is small, the initial symptoms are not obvious, but after 2 to 3 days, as the pleural fluid increases, the symptoms such as dyspnea gradually increase, and it needs to be differentiated from the empyema.
