– the pathological congestion of lymphatic (hilezny) liquid in a pleura cavity arising owing to a limforea from a chest channel. Development of a hilotoraks is followed by short wind, the progressing deterioration in health, a kollaptoidny state, exhaustion, respiratory insufficiency. it is diagnosed on kliniko-anamnestichesky yielded, to results of a X-ray analysis, torakotsentez, cytologic assessment of hilezny liquid, a torakoskopiya. Treatment of a hilotoraks includes repeated punctures or drainage of a pleural cavity for removal of a hilus, at a persistent limforea - bandaging of a chest lymphatic channel, plevroperitonealny shunting, , imposing of a limfovenozny anastomoz, etc.
- rather rare pathology which develops as a result of violation of integrity of a chest lymphatic channel and receipt in a cavity of a pleura of the lymphatic (hilezny) liquid circulating on it. can be followed considerable limforey (the expiration of a lymph) - to 4-5 l a day and to lead to the deep respiratory, exchange and immunological violations in an organism posing a threat for the patient's life in connection with loss of fats, proteins, vitamins, electrolytes, lymphocytes. it is noted in all age groups, in t of h and at newborns.
Hilezny liquid has whitish coloring, contains a large number of the hilomikron which are the main transport form of triglycerides, cholesterol and exogenous fatty acids. Hilomikrona are formed in epitelialny cages mucous intestines; after absorption on lymphatic ways come to the chest lymphatic canal and further to the blood circulatory system. At a hilotoraksa, except the high content of lipids (more than 1,1 mmol/l), in pleural hilezny exudate excess of total of cellular elements (more than 1000 in ) and lymphocytes (more than 90%) is observed.
In clinical practice with hilotoraksy experts should face in the field of pulmonology, thoracic surgery, traumatology, a heart surgery, gastroenterology, oncology, phthisiology, a flebologiya and a limfologiya.
Reasons of a hilotoraks
is the secondary disease or a complication connected with pathology of lymphatic vessels. Depending on etiologichesky factors distinguish the following types of a hilotoraks: congenital, traumatic and not traumatic. Also allocate idiopathic , developing at smokers with a long-term experience.
Congenital , shown in the period of a neonatality and at children's age, it can be caused by a hereditary atresia of a chest lymphatic channel, existence of fistula between its lower piece and a pleural cavity. At primary persistiruyushchy hilotoraks of a fruit it is not always possible to establish an obvious cause of illness (in rare instances it can be hereditary limfangiektaziya).
Traumatic (yatrogenny) develops at mechanical damage of a chest lymphatic channel or its main branches during surgeries (thoracic, cardiac, abdominal, spinal), diagnostic procedures (translyumbalny arteriography, a kateterization of a subclavial vein or the left departments of heart, an ezofagoskopiya), owing to a stupid injury or the getting wound of a thorax and area of a neck. At damage of a chest lymphatic channel higher than the level V-VI of chest vertebras is formed left-side , below – right-hand.
not traumatic genesis often arises in the presence of various good-quality and malignant new growths affecting lymphatic system of area of a sredosteniye and a neck (a mediastinalny malignant nekhodzhkinsky lymphoma, a good-quality lifangioma of a channel, a limfangiomatoz of a sredosteniye, pleura cancer). Can lead intra chest tuberculosis to development of a hilotoraks and , mediastinit, ascending limfangit, , diafragmalny hernia, etc.
The congestion of hilezny liquid in a pleural cavity can be noted at the syndrome of the top hollow vein which is followed by increase in venous pressure and hypertensia in system of a chest lymphatic channel. can sometimes be result of the extended hilezny ascites at the combined limfangioleyomiomatoz of lungs, a sredosteniye, abdominal organs and zabryushinny cellulose.
The spontaneous rupture of a wall of a lymphatic vessel at cough and increase in pressure in naddiafragmalny area is the cornerstone of an idiopathic hilotoraks. develops owing to synchronization of a pleural exudate (at tuberculosis, rheumatoid arthritis). Psevdokhilezny exudate has muddy milky-white color with a peculiar opalestsiruyushchy gloss and high content of cholesterol.
Symptoms of a hilotoraks
Gradual development is characteristic of a postoperative hilotoraks: it is connected with the sparing diet during the rehabilitation period, insignificant quantity of a lymph, its slow penetration into a pleural cavity. Therefore postoperative it is, as a rule, distinguished only for 2-10 days after surgery. Clinical manifestations arise when the volume of a hilezny exudate reaches 200 and more than a ml.
Short wind which in process of increase of a hilotoraks can progress to respiratory insufficiency is the first sign. Weight in the corresponding half of a thorax, tachycardia, hypotonia, development of a kollaptoidny state is noted. Unlike ekssudativny pleurisy, for a hilotoraks thorax pains and a hyperthermia as the lymph does not cause irritation of a pleura are atypical and thanks to the bakteriostatichesky properties it is capable it is long not to be infected.
Is critical to 1,5-2 l a day since together with a lymph a significant amount of protein, fats, electrolytes, lymphocytes is lost. The long or massive expiration of a lymph causes development of metabolic violations and an immunodeficiency, exhaustion of the patient therefore can lead to his death.
Diagnostics of a hilotoraks
Fizikalny data at a hilotoraksa remind symptoms of pleurisy. Obtusion of a perkutorny sound and weakening of breath on the party corresponding to defeat is defined. By means of a X-ray analysis of lungs existence of an exudate in a pleural cavity, preload of a lung and shift of a sredosteniye is defined. Clarification of the reasons of a hilotoraks requires carrying out UZDG of lymphatic vessels, limfangiografiya, limfostsintigrafiya and KT of a thorax.
On the basis of a radiological picture and data of ultrasonography of a pleural cavity the diagnostic pleural puncture is carried out. At a hilotoraksa receive hilezny liquid of milky-white color. The analysis of a pleural exudate finds oily character of exudate, high content of lymphocytes, typical for a lymph, triglycerides, total of cellular elements. At a hilotoraksa in blood the limfopeniye and a gipoproteinemiya accrue.
For clarification of the exact reason of not traumatic hilotoraks carrying out a biopsy of a lymph node, pleura, tissue of a lung, a diagnostic torakoskopiya or mediastinoskopiya with a morphological research of biopsiyny material can be required.
Treatment of a hilotoraks
Treatment of a hilotoraks is begun with conservative methods: with their help it is possible to reach the spontaneous termination of a limforea almost at 50% of patients with a malosimptomny or asymptomatic hilotoraks. At conservative maintaining a hilotoraks make drainage of a pleural cavity with installation of a constant drainage or a series of pleural punctures with evacuation of hilezny liquid. Thereby the decompression of a lung and bodies of a sredosteniye, reduction of respiratory frustration is reached.
For reduction of development of a hilus of the patient completely transfer to parenteral food or appoint a high-calorific diet with restriction of fats. For the purpose of correction of a gipoproteinemiya and electrolytic frustration at a hilotoraksa infusional therapy is carried out by proteinaceous and salt medicines. For a rassasyvaniye of an exudate intravenous administration of a somatostatin is successfully used.
At unsuccessfulness of conservative actions and proceeding limfory transition to surgical tactics is expedient. The main types of operations which are carried out at a hilotoraksa are plevroperitonealny shunting, bandaging of a chest lymphatic channel is higher and lower fistulas, an obliteration of a pleural cavity talc (), imposing of a limfovenozny anastomoz. Successful cases of an embolization of a lymphatic channel at adult patients are described. At the hilotoraks caused by tubercular process specific treatment is shown; at a tumoral etiology – himioluchevy therapy.
Forecast and prevention of a hilotoraks
The lethality at a hilotoraksa makes from 15 to 50%. Predictively the current of a hilotoraks at malignant new growths of a chest cavity is adverse. At timely diagnostics and complex treatment of a traumatic hilotoraks in most cases it is possible to achieve positive results.
The prevention of a yatrogenny hilotoraks consists in careful and justified carrying out diagnostic manipulations, invasive medical procedures, surgeries. At thorax injuries it is always necessary to remember a possibility of damage of a chest lymphatic channel and development of a hilotoraks. Prevention of an idiopathic hilotoraks dictates need of refusal of smoking.