Celiac disease is caused by the rupture or obstruction of the thoracic duct for different reasons, resulting in the overflow of celiac fluid into the chest cavity. The thoracic duct is the largest lymphatic duct in the body, with a total length of about 30-40 cm. It is divided into two parts, one is the manifestation of the original disease; the other is the symptoms of celiac disease itself. In traumatic rupture of the thoracic duct, celiac fluid overflows rapidly and can produce symptoms of compression.
Celiac disease is caused by rupture or obstruction of the thoracic duct for different reasons, causing celiac fluid to overflow into the chest cavity. The thoracic duct is the largest lymphatic duct in the body, with a total length of about 30~40 cm. It starts from the celiac pond in front of the first lumbar vertebra in the abdominal cavity, goes up through the aortic foramen and crosses the diaphragm into the mediastinum. It then travels up along the right anterior side of the vertebral body and the posterior side of the esophagus and crosses the vertebral body at the fifth thoracic vertebrae obliquely to the left. It travels up the left side of the vertebral body and esophagus to the neck, returns across the subclavian artery posterior to the carotid sheath and injects into the left venous angle.
Causes
Celiac disease is caused by the accumulation of celiac fluid in the thoracic cavity due to blockage or rupture of the thoracic duct, which has various causes, with injury, tuberculosis, filariasis, and tumor causing the most common.
They can be roughly divided into two main categories.
(a) Traumatic chest trauma or intrathoracic surgery: such as esophageal, aortic, mediastinal or cardiac surgery may cause injury to the thoracic duct or its branches, causing celiac fluid to spill out into the pleural cavity. Sometimes hyperextension of the spine can also cause rupture of the thoracic duct.
(B) Obstructive intrathoracic tumors: such as lymphosarcoma, lung cancer or esophageal cancer compressing the thoracic duct to infarct, the proximal end of the obstructed thoracic duct ruptures the thoracic duct or its lateral branch system due to overexpansion and elevated pressure. Obstruction of the thoracic duct caused by filariasis is very rare at present.
Other causes of celiac disease are rare, including congenital anomalies of the mediastinum or pulmonary lymphatics, and occasionally celiac disease in newborns. In rare cases of portal hypertension in cirrhosis, the infiltration of subpleural lymphatic fluid due to thrombosis or other causes of obstruction of large veins in the upper part of the body or pulmonary lymphangioangioma may cause celiac disease on one or both sides.
Pathophysiology
Celiac disease contains more fatty material than plasma, abundant lymphocytes, and considerable amounts of proteins, sugars, enzymes, and electrolytes. Once the thoracic duct ruptures, a large amount of celiac fluid leaks into the pleural cavity, which inevitably leads to two serious consequences: first, the loss of a large amount of nutritious celiac fluid inevitably causes severe dehydration, electrolyte disorders, nutritional disorders and depletion of a large number of antibodies and lymphocytes, which reduces the resistance of the body; second, the accumulation of a large amount of celiac fluid in the pleural cavity inevitably leads to compression of the lung tissue, displacement of the mediastinum to the opposite side and Second, the accumulation of large amounts of celiac fluid in the pleural cavity inevitably leads to the compression of the lung tissue, the displacement of the mediastinum to the opposite side and the partial obstruction of the large veins returning to the cardiac blood flow, which further aggravates the deficiency of blood volume in the body circulation and cardiopulmonary failure.
The amount of celiac fluid infiltrated into the pleural cavity varies from 100-200 ml per day for small cases to 3000-4000 ml per day for large cases, depending on the size of the thoracic duct incision, the negative pressure in the pleural cavity, the amount of intravenous fluids and their rate, and the nature of the ingested food.
Clinical manifestations
1, chest tightness and shortness of breath, especially when there is a lot of activity or eating more fatty food.
2, a small amount of celiac pleural fluid may not have positive signs; when the amount is large, the respiratory movement on the affected side is weakened, turbid percussion and breath sounds are weakened or disappear.
Diagnosis basis
1, chest tightness and shortness of breath.
2.Signs of pleural effusion, chest X-ray suggests pleural effusion.
3.Thoracic puncture can extract milky white fluid, and celiac disease is positive. Treatment
Treatment principles
1.Treat the original disease.
2.Low-fat diet.
3.Intravenous supplementation of fatty milk, albumin, etc.
4.Thoracic aspiration or closed drainage of the chest cavity.
5.Surgical treatment is feasible if medical treatment is ineffective.
Medication principles
1.Celiac disease caused by tuberculosis, the basic drugs 4-7 and 1 can be chosen.
2.For celiac disease caused by filarial granuloma, basic drugs 1-3 and furazolidone can be chosen.
Treatment.
Once celiac disease is diagnosed, fasting, blood transfusion, intravenous rehydration, and high nutritional support should be taken immediately, and thoracentesis or closed drainage can make the lung completely expand. Those caused by malignant tumors should treat the tumor with radiation. 1/2 of the patients can be treated conservatively, while the other 1/2 need surgery.
Conservative treatment methods.
1.Fastening, intravenous rehydration, high nutritional support, closed drainage of the chest cavity;
2.Use growth inhibitors to inhibit celiac production;
3, intra-thoracic injection of pleural adhesives to promote pleural adhesion to close the thoracic duct fistula;
4.After successful treatment, gradually resume normal diet.
Surgical treatment methods.
1.Surgical indications: acute onset and caused by trauma; progressive increase in pleural fluid, caused by the failure to reduce; general condition is still good, not caused by malignant tumor invasion; conservative treatment is ineffective, should be given active surgery.
2.Preoperative preparation: fully correct malnutrition and electrolyte disorder before surgery, give blood transfusion, high protein, control respiratory tract infection, and give high-fat diet 3~4 hours before surgery, which helps to find the thoracic duct and its breakage site during surgery.
3.Surgical treatment.
(1) Anesthesia, intravenous complex anesthesia with tracheal intubation.
(2) Reclining position, often in the left recumbent position, right side surgery, or left side surgery can be done.
(3) Ligation of thoracic duct through the right chest
The right posterior lateral incision is made through the 5th or 6th intercostal space into the chest, aspirate the intrathoracic fluid, push the lung forward, expose the posterior mediastinum, look for a white translucent 4~5mm thick thoracic duct between the odd vein and the aorta, double ligate it with thick thread at both ends of the breach, then aspirate the fluid with gauze, and carefully observe whether there is any leakage.
(4) Transthoracic ligation of the thoracic duct
Then the mediastinal pleura was cut above the aorta, and the thoracic duct was found behind the subclavian artery and double ligated. If the rupture was under the aortic arch, the thoracic duct was found between the odd vein and the aorta and ligated according to the right approach to the chest.
(5) Surgical results, except for those caused by malignant tumor invasion and compression, generally the patient heals well after proper surgical ligation.
Complications
1.Anastomotic fistula: This is a serious complication of esophageal cancer after surgery, with an incidence rate of about 5%. The reasons for its occurrence are related to the anastomosis method, the tension of the anastomosis, the secondary infection of the anastomosis and the nutritional status of the patient before surgery. Anastomotic fistula usually occurs 4 to 6 days after surgery, or later. Once it occurs, timely and adequate drainage or reoperation should be performed.
2. Anastomotic stenosis: It occurs mostly 2 to 3 weeks after surgery, or as late as 2 to 3 months later, and patients mainly have varying degrees of dysphagia. The anastomotic stricture is related to the anastomotic method, anastomotic infection, anastomotic leakage and the patient’s own scar body, etc. If the diagnosis is confirmed by examination, esophageal dilation or intraluminal stent dilation can be performed, and if the effect is not good, resection of the stricture and re-anastomosis are also feasible.
3.Pulmonary complications: Most of the patients with esophageal cancer are of higher age and often have different degrees of lung diseases. After surgery, they are reluctant to cough up sputum due to incision pain and other reasons, resulting in retention of bronchial secretions and easy to complicate pneumonia and pulmonary atelectasis. Once pulmonary infection occurs, the dosage of antibiotics should be increased, and drug sensitivity test and sputum culture should be performed to select sensitive antibiotics. Give sputum-cleansing drugs to facilitate coughing up of sputum, and perform nasal catheter aspiration or fiberoptic bronchoscopy aspiration if necessary.
4.Pustulothorax: Since bacteria exist in the esophagus under normal circumstances, esophageal cancer surgery is a contaminated surgery and can be complicated by pustulothorax after surgery. The treatment principle of abscess chest is to perform closed drainage of chest cavity and apply antibiotics.
5.Celiac disease: The thoracic duct is an anatomical structure for draining the abdominal cavity and part of the thoracic lymphatic fluid, which is accompanied by the esophagus and may be damaged in the surgery. If the tumor invasion is obvious, it is more likely to be damaged. Thoracic duct injury is manifested by celiac fluid draining from the thoracic cavity, with a daily drainage rate of 500 ml or more. Once the diagnosis of celiac disease is confirmed, closed drainage of the chest cavity should be performed and observed for 1 to 2 days, if there is no sign of healing, the thoracic duct break should be ligated and sutured again, and should not be delayed for too long.