Celiac disease is caused by rupture or obstruction of the thoracic duct for different reasons, causing celiac fluid to overflow into the thoracic cavity. The thoracic duct is the largest lymphatic duct in the body, with a total length of about 30-40 cm. It originates from the celiac pond in front of the first lumbar vertebra in the abdominal cavity and travels upward through the aortic foramen through the diaphragm and into the mediastinum. It then travels upward 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 and injects the left venous angle (where the left jugular vein meets the left subclavian vein) by crossing the subclavian artery posterior to the carotid sheath. The thoracic duct drains the lymphatic fluid below the diaphragm and the left half of the upper diaphragm. According to studies, 60% to 70% of the body’s fat intake is collected by the lymphatic vessels of the mucosal villi and converges into the celiac pond. They are injected into the thoracic duct via the thoracic duct into the thoracic circulation. celiac flow and properties vary with diet, usually about 60-100 ml per hour, with a daily total of about 1,5-2,5 L. When fatty foods are eaten, the flow increases and becomes celiac, while when starving or fasting, the amount is less and brighter. Celiac disease was first reported by Bartolet in 1633. With the increase in thoracic surgery, the incidence has increased each year. More than 130 cases were reported in Chinese journals from 1980 to the early 1990s, with more males than females with celiac disease. Celiac disease can be divided into two categories: congenital and traumatic (medical non-medical, spontaneous), with traumatic and medical injuries being more common. When the thoracic duct is compressed or blocked, the pressure inside the duct increases, causing the duct or its branches in the mediastinum to rupture and rupture the celiac fluid into the mediastinum, and then penetrate the mediastinum into the thoracic cavity, forming celiac pleural effusion. Due to anatomical reasons, when the obstruction or compression occurs below the fifth thoracic vertebra, only the right side of celiac disease appears, and above the fifth thoracic vertebra, bilateral celiac disease appears. Clinical manifestations One is the manifestation of the primary disease; one is the symptom of celiac disease itself traumatic thoracic duct rupture celiac fluid overflow rapidly, which can produce compression symptoms, such as shortness of breath, dyspnea, mediastinal shift, etc. Those caused by diseases are less symptomatic. Malnutrition due to excessive fat and protein-electrolyte loss or immune deficiency due to excessive T-lymphocyte loss may occur. Complications: Severe cases are complicated by malnutrition. Diagnosis: 1. History (1) A history of chest surgery, closed chest injury, violent cough or vomiting, hyperextension of the spine or fracture and other rare causes may also lead to thoracic duct tears; (2) The most common mediastinal malignancies are lymphoma, lymphangioleiomyomatosis, thoracic duct lymphangitis, tuberculosis, superior vena cava obstruction syndrome, connective tissue disease (systemic disseminated lupus erythematosus, leukodystrophy, etc.) filariasis Kaposi’s sarcoma is often secondary to acquired immunodeficiency syndrome (AIDS), which can lead to celiac disease; (3) in a few congenital cases, the cause is abnormal development of the thoracic duct, such as dilatation, defect, atresia or fistula formation. 2.Clinical manifestations There are two parts, one is the manifestation of the primary disease; the other is the symptoms of celiac disease itself. Traumatic thoracic duct rupture and rapid overflow of celiac fluid can produce compression symptoms, such as shortness of breath and mediastinal displacement. Those caused by diseases are less symptomatic. Malnutrition may occur due to excessive loss of adiponectin and electrolytes, or immune deficiency due to excessive loss of T lymphocytes. 3.Diagnosis The diagnosis of celiac disease relies on the examination of pleural fluid and determines that milky pleural fluid has a high diagnostic value, but the following 2 points should be noted in the differentiation. ① In true celiac fluid, only 50% of it is milky. It is generally white and cloudy, but can also be pale yellow or pink and odorless. The specific gravity is between 1,012 and 1,025, pH is alkaline (7,40 to 7,80), protein > 30 g/L cell count is low, mainly lymphocytes [(0,4 to 6,8) × 109/L], rare neutrophils, and bacterial culture is negative fat droplets are visible under the microscope. The fat content of celiac fluid is usually >40 g/L, with high triglyceride (TG) content (diagnosed when >1,1 g/L, and excluded if <0,5 g/L) and low cholesterol content, with cholesterol/triglyceride <1,0; ② milky pleural fluid is not always celiac, but may be pseudo-celiac fluid formed by abscess pleural or cholesterol pleurisy. True celiac fluid becomes clear after shaking with ether due to fat precipitation, high fat and triglyceride content, positive Sudan III staining, and celiac particle bands visible in lipoprotein electrophoresis. Pseudo celiac disease cannot be cleared by shaking with ether, and cholesterol crystals or a large number of degenerative cells can be seen with the naked eye or microscope. Further radionuclide lymphadenography or x-ray lymphadenography is performed to observe lymphatic vessel obstruction and lymphatic vessel overflow sites. lymph nodes or other masses along the thoracic duct. This is necessary to determine the cause. Celiac disease - treatment The treatment plan for triglycerides depends on the cause. The amount of celiac disease and the duration of the disease are usually treated with a combination of treatments. 1. Etiological treatment Malignant tumors are the main cause of celiac disease. Among them, lymphoma is the most common. Such patients respond better to radiotherapy and chemotherapy, and some patients have their tumors shrink after treatment and the compression of the superior vena cava or thoracic duct is released, and celiac disease disappears. Radiation therapy is also effective for celiac disease caused by Kaposi's sarcoma. Patients with tuberculosis should be treated with anti-tuberculosis therapy. 2.Symptomatic treatment Reducing the amount of food eaten and taking low-fat diet can reduce the production of celiac fluid. Fasting, gastrointestinal decompression and intravenous hyper-nutrition therapy can be used to block the formation of celiac fluid and facilitate the repair of damage to the thoracic duct in cases of rapid and large overflow. Palm oil or coconut oil rich in medium-chain triglycerides can be consumed to prevent the occurrence of malnutrition and reduce celiac fluid formation. This is because medium-chain triglycerides, unlike long-chain fatty acids, are not involved in celiac formation after absorption from the intestine, but enter the liver via the portal vein. Thoracic drainage and pleural adhesions: puncture aspiration or closed drainage can relieve compression symptoms. Pleural adhesions are also feasible to occlude the pleural cavity to stop the accumulation of celiac fluid. The method is to inject tetracycline (20mg/kg), tetracycline powder 0,5~1,0g, dissolved in 100ml saline into the pleural cavity on the basis of drainage as much as possible, puncture or inject from the closed drainage tube into the pleural cavity, ask the patient to turn the body position repeatedly, let the medicine evenly coat the pleura, especially the lung tip if the drainage tube is to be clamped for 24h, observe 2~3 days by chest X-ray or film to confirm that the pneumothorax has The drainage tube can be removed after 2-3 days of observation and confirmation of absorption and cure by chest X-ray or radiograph. Cold precipitation (fibrin factor VIII, fibrinogen and thrombin) can also be used, this product belongs to human physiological substances, the side effects are light, a few patients have transient liver function damage, generally 1 to 2U added to 5% calcium chloride solution 10ml and tranexamic acid 250mg, in 1 to 5 times sprayed into the chest cavity, the success rate is high recurrence rate of 3, 7% autologous blood 10 to 15ml intrathoracic injection can be repeated several times . Short rod bacillus preparations, etc., to produce sterile inflammatory adhesions in the pleural cavity. Due to the low eradication rate of pleural adhesions and the large side effects, there is a tendency to use thoracic surgical therapy. 3.Surgery Patients with large overflow celiac disease, who have no significant effect after regular medical treatment (including fasting gastrointestinal decompression and intravenous high nutrition, etc.) for more than two weeks, should be operated as early as possible to prevent malnutrition. The surgical method is to open the chest or to find the thoracic duct fissure through thoracoscopy, and to repair the fissure with sutures or to ligate it. When it is difficult to find the incision after opening the chest or when it is difficult to separate the tumor-embedded fiber adhesions; the thoracic duct can be ligated at the aortic fissure on the diaphragm, and thoracoabdominal diversion is feasible for patients with intractable celiac disease. On the second day after the operation, 200 ml of milk-like drainage fluid appeared after enteral nutrition. The diagnosis of celiac disease was clear. I don't know how much enteral nutrition fluid there is per day. If it is less than 800 ml per day and tends to decrease gradually, it can be successfully treated conservatively. The main thing is adequate negative pressure drainage to ensure full expansion of the lung, early formation of adhesions and closure of the leak of the chest tube. Intrathoracic injection of adhesives, such as talcum powder, tetracycline powder, etc., is also possible. After fasting the chest tube without drainage fluid for about a week, take a chest X-ray to see the degree of lung expansion and the presence of fluid wrapping, if normal you can try a clear - fluid diet. The chest tube can be removed after 3 days of feeding. In esophageal cancer surgery, if the tumor is too large, and contralateral pleural infiltration, or the lesion is behind or under the arch, the thoracic duct should be ligated intraoperatively, and the descending aorta should be drawn to the left side at 3-4 cm above the diaphragm, and the lateral edge of the aorta should be separated immediately to the prevertebral fascia with pointed forceps to enlarge the separation (sometimes the thoracic duct can be seen). The thoracic duct is then separated with a more curved forceps arcing downward, tightly against the anterior vertebral fascia, and then the curved forceps are reversed and the thoracic duct is ligated in the large bundle of separated tissue. Care is taken not to damage the odd vein. If the closed chest drainage is less than 100 ml for 24 hours, an orthopantomogram of the chest is taken, and then two days after closing the drainage tube, the two films are compared, and if there is no change in the amount of fluid accumulation, the tube can be removed.