Chylothorax
Introduction
Introduction to chylothorax Different causes of the chylothorax lead to rupture or obstruction of the thoracic duct, causing the chyle to overflow into the chest. 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, passes through the transverse aorta through the aortic sulcus and enters the mediastinum, and then moves up the right front of the vertebral body and the posterior esophagus, and obliquely to the left upper part of the vertebral body 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: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: nephrotic syndrome cirrhosis
Cause
Chestnut chest disease
(1) Causes of the disease
The chylothorax can be divided into two types: congenital and traumatic (iatrogenic, non-iatrogenic, spontaneous), and traumatic and iatrogenic injuries are more common.
(two) pathogenesis
When the thoracic catheter is compressed or blocked, the pressure in the tube is increased, causing the catheter or its branch to rupture in the mediastinum. The chyle falls back into the mediastinum, and then penetrates the mediastinum into the chest cavity to form a chylothorax effusion. The pressure of the thoracic duct is high, and the intrapulmonary and intercostal lymphatic vessels are dilated and refluxed. The chyle is directly leaked into the thoracic cavity without the mediastinum. For anatomical reasons, the obstruction or compression occurs below the fifth thoracic vertebra, only the right is present. Lateral chylothorax, in the fifth thoracic vertebra, there is bilateral chylothorax.
Prevention
Chylons prevention
Once diagnosed, the primary tumor should be removed in time to reduce comorbidities.
Complication
Chyle chest complications Complications nephrotic syndrome cirrhosis
Severe cases are complicated by malnutrition, immunodeficiency and so on.
Symptom
ChylHous chest symptoms Common symptoms Difficulty breathing Dizziness Nutritional disorders Dehydration
It is divided into two parts, one is the primary disease manifestation; the other is the symptoms of the chylothorax itself, the traumatic thoracic duct rupture, the chyle overflows quickly, and can produce symptoms of compression, such as shortness of breath, difficulty in breathing, mediastinal shift, etc. There are few symptoms, which may be caused by excessive loss of fat, protein, electrolytes, or malnutrition due to excessive loss of T lymphocytes.
History
(1) There are rare cases of chest surgery, chest closed injury, severe cough or vomiting, excessive stretching or fracture of the spine, and may lead to tearing of the thoracic duct.
(2) mediastinal malignant tumors, the most common are lymphoma, lymphangiomyomatosis, thoracic duct lymphangiitis, tuberculosis, superior vena cava obstruction syndrome, connective tissue disease (systemic disseminated lupus erythematosus, Behcet's disease) Etc.), filariasis, nephrotic syndrome, cirrhosis, etc., Kaposi sarcoma is often secondary to acquired immunodeficiency syndrome (AIDS), which can cause chylothorax.
(3) A small number of congenital persons are caused by malformation of the thoracic duct, such as dilatation, defect, atresia or fistula formation.
2. Clinical manifestations
Divided into two parts, one is the primary disease manifestation, one is the symptoms of chylothorax itself, the traumatic thoracic duct rupture, the chyle overflows quickly, can produce symptoms of compression, such as shortness of breath, difficulty breathing, mediastinal shift, etc. There are few symptoms, which may be caused by excessive loss of fat, protein, electrolytes, or malnutrition due to excessive loss of T lymphocytes.
Examine
Chest chest examination
1. The appearance of pleural effusion 0.50 is milky, 0.12 is serous or serous. After placement, there is an oily film on the upper layer, which is still cloudy after centrifugation.
2. Pleural effusion examination of pleural fluid triglyceride is often > 2.75mmol / L, and higher than plasma, cholesterol / triglyceride <1.
X-ray examination: the flat film is more moderate, and a large amount of fluid image can be used to observe the lung, mediastinum, pleural primary and metastatic tumor through CT. Lymphangiography can be used to identify the location of the thoracic duct and the location of the rupture.
Diagnosis
Diagnosis of chylothorax
diagnosis
The diagnosis of chylothorax is determined by pleural effusion examination, and the milky pleural effusion has a high diagnostic value.
Further radionuclide lymphangiography or X-ray lymphangiography is necessary to observe lymphatic obstruction and lymphatic extravasation. It is feasible to perform CT scan of the chest and abdomen to understand whether there are enlarged lymph nodes or other masses along the thoracic duct. This is necessary to determine the cause.
Differential diagnosis
Clinically, it must be differentiated from empyema and pseudo-chypothelium. The following two points should be noted in the identification:
1 In true chyle, only 50% is milky, generally white turbid, can also be light yellow or pink, no odor, specific gravity between 1.012 ~ 1.025, pH partial alkali (7.40 ~ 7.80), protein > 30g / L, the number of cells is small, mainly lymphocytes [(0.4 ~ 6.8) × 109 / L], rare neutrophils, bacterial culture is negative, microscopically visible fat droplets, milk fat content of milk mites generally > 40g /L, high triglyceride (TG) content (diagnosable when >1.1g / L, can be ruled out if <0.5 g / L), lower cholesterol, cholesterol / triglyceride <1.0.
2 milky pleural effusion is not all chylothorax, but may be pseudo-chylorrhea formed by empyema or cholesterol pleurisy. True chyle and ether sway after clearing due to fat precipitation, high fat and triglyceride content, Sudan III staining positive, lipoprotein electrophoresis showed chylomicron band, pseudo chyle and ether shaking can not become clear, macroscopic or microscopically visible high-resolution crystallized crystals or a large number of degenerative cells, no fat globules and chylomicrons, more cholesterol Up to 2.5g / L.
