Chyloma
Introduction
Introduction to chylomicron The chyloperitoneum is an accumulation of intra-abdominal chyle caused by abnormal leakage of chyle in the peritoneal lymphatic system. This disease is rare and the cause of the disease is complicated, but it is caused by congenital developmental disorder and can also be caused by trauma. The disease has a great impact on the nutritional development of patients, and the prognosis is good in timely diagnosis and treatment. The disease can be manifested as acute peritonitis and chronic peritonitis. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: non-infectious Complications: abdominal pain
Cause
Celiac disease
The causes of chylorrhea are complex, and there are two types of congenital chylothorax and acquired chylothorax.
Congenital abnormalities of lymphatic vessels (26%):
Congenital chylothorax is caused by congenital abnormalities of abdominal lymphatic vessels, that is, thoracic duct, mesenteric lymphatic trunk or chyle pool, such as hypoplasia, lack of, stenosis, etc., resulting in increased intestinal lymphatic pressure, expansion and rupture, or congenital Cracks.
Intraperitoneal infection (25%):
Intra-abdominal infections, especially mesenteric lymph node tuberculosis or tuberculous peritonitis, may be secondary to chylothorax. Tuberculous peritonitis is a chronic, diffuse inflammation of the peritoneum caused by Mycobacterium tuberculosis. The path of infection of this disease can be directly spread by intra-abdominal tuberculosis or disseminated by blood.
Trauma (20%):
Congenital chylothorax can cause the occurrence of chylothorax due to trauma or surgical damage to the lymphatic trunk. Tumor or fiber band compression can cause lymphatic obstruction, distal lymphatic stasis, expansion, rupture, and formation of chylothorax.
There are differences in the proportion of causes of chylorrhea in the literature. Some people have statistics on the causes of 56 children: congenital 39%, followed by idiopathic (31%), secondary to intra-abdominal infections 15%, trauma 12% of the sexes, tumors (3%), the author experienced 19 cases of surgical treatment, 2 cases (10.5%) of the trauma, 2 cases (10.5%) of the intra-abdominal infection, and 7 cases of the rupture of the chyle in the operation. They are all infants within 1 year of age, and the indications are congenital, accounting for 36.8%. The remaining half of the cases are unknown.
Pathogenesis
The fat in the food is decomposed into fatty acids and monoglycerides by digestion. After being absorbed by the intestinal mucosal epithelial cells, they are synthesized into triglycerides by the body and then enter the lymphatic vessels in the form of chylomicrons, which constitute the main component of the chyle. Through the mesenteric lymphatics flowing into the chyle pool, and then into the thoracic duct, and then into the neck of the unknown vein, the lymph in the small intestine lymphatic, chyle and thoracic duct is white emulsion, odorless, alkaline reaction, the specific gravity is 1.0101.021, after standing, it can be divided into 3 layers, the upper layer is milky, the middle layer water sample, the lower layer is white precipitate, the white blood cell count is about 5×109/L, mainly lymphocytes, and the culture has no bacterial growth.
The chyle leaks into the abdominal cavity and stimulates the aseptic chemical inflammation of the peritonitis. The peritoneal and mesenteric congestion, edema, hypertrophy, the submucosal lining of the intestinal wall is covered with white finely curved chyle tube streaks, the intestine is pale, histological examination: peritoneal thickening , fibrous tissue hyperplasia, covered with a layer of inflammatory exudate, vasodilatation, congestion, hemorrhage, and scattered in the infiltration of chronic inflammatory cells, granulation tissue formation, showing chronic proliferative peritonitis.
Prevention
Celiac prevention
Congenital chylothorax is caused by congenital abnormalities of the abdominal lymphatic vessels, ie, hypothalamic, total mesenteric lymphatic trunk or chyle pool, such as hypoplasia, absence, stenosis, etc., resulting in increased intestinal lymphatic pressure, dilatation and rupture or congenital fissure. Precautions need to be done before and during pregnancy to achieve early detection and early treatment.
Congenital chylothorax can cause the occurrence of chylothorax due to trauma or surgery damage to the lymphatic canal. Intra-abdominal infection, especially mesenteric lymph node tuberculosis or tuberculous peritonitis can be secondary to chylothorax, tumor or fiber band compression can make lymph The tube is obstructed, and the distal lymphatics are stagnant, dilated, and ruptured to form a chyle. Prevention needs to do the treatment of the primary disease, try to avoid trauma.
Complication
Ruminal complications Complications, abdominal pain
The chyle is rich in nutrients, and a large amount of loss for a long time will cause hypoproteinemia in the body and is prone to secondary bacterial infection.
Symptom
Celiac abdominal symptoms Common symptoms Abdominal pain, bloating, peritonitis, diarrhea, nausea, hypoproteinemia, intestinal perfusion, ascites, abdominal wall, venous distraction, mobile dullness
The disease can be manifested as acute peritonitis and chronic peritonitis.
Acute peritonitis
Rarely, more than a large number of eating, especially 4 to 6 hours after the fat meal, the acute chemical peritonitis caused by the sudden rapid entry of the chyle into the abdominal cavity, manifested as acute abdominal pain, the initial range of abdominal pain is wide, the position is uncertain, sometimes colic, and Gradually exacerbated, accompanied by nausea, vomiting, abdominal distension, total abdominal tenderness or localized tenderness, often manifested as localized lower extremity or left lower abdomen localized tenderness and muscle tension, early bowel sounds hyperthyroidism, late bowel sounds weakened, often misdiagnosed Perforation for acute appendicitis or ulcer disease.
2. Chronic peritonitis
The chyle slowly leaked into the abdominal cavity, the peritoneal stimulation was lighter, the inflammatory reaction was lighter, and there was no obvious peritoneal irritation. The abdominal augmentation, weight loss or no increase, chyle diarrhea, hypoproteinemia and malnutrition, serious Can affect breathing, circulatory function, abdominal examination can be seen abdominal distension, abdominal wall venous engorgement, abdominal percussion has mobile dullness, fluid tremor is positive, some can see scrotal effusion, or scrotum and lower extremity edema.
Examine
Celiac examination
Abdominal puncture was performed to take chyle-like ascites for examination.
1. Ascites properties: milky white, alkaline, specific gravity 1.010 ~ 1.021, stratified after standing; Sudan fat staining was positive.
2. White blood cell count and classification: Ascites white blood cell count is about 5 × 109 / L, mainly lymphocytes.
3. Bacteriological examination: no bacterial growth.
Film degree exam
1. Abdominal B type: Ultrasound examination can find a large amount of ascites.
2. Lymphangiography: not only can determine the cause, but also determine the location and extent of the lymphatic leak.
Diagnosis
Diagnosis of chylothorax
Abdominal puncture to extract chyle-like ascites is the simplest and most reliable diagnostic method, according to the nature of ascites, white blood cell count, bacteriological examination and so on.
Lymphangiography can detect compression, obstruction, dilatation or variability in the lymphatic vessels adjacent to the temporal and paraspinal. The clinical manifestations are mainly symptoms of ascites, followed by the symptoms of the primary disease. The course of the disease is mostly slow, and occasionally begins with acute abdomen. Lymphatic edema can occur in the lower extremities due to reflux of the chyle. It is also possible to have both chylothorax and chyluria.
