Chyluria
Introduction
Introduction to chyluria Chyluria has a higher recurrence rate of intestinal absorption nutrient chyluria. According to relevant reports, it is generally about 20%~30%. The causes of recurrence are overwork, alcoholism, high fat meal, cold fever, prenatal and postpartum, etc. . The chyloplast formed by the meridian is blocked by the lymphatic vessels and flows back into the lymphatics of the urinary system, causing the pressure in the lymphatics of the urinary system to increase, the varicose veins to rupture, and the chyle into the urine. It contains protein, fat and lymphocytes. If it is chyluria to filariasis, red blood cells can generally be seen in urine sediment. The recurrence rate of chyluria is relatively high. According to relevant reports, it is generally about 20%~30%. The causes of recurrence are overwork, alcoholism, high fat meal, cold fever, and prenatal and postpartum. The age of onset of chyluria is the highest in 30 to 60 years old. basic knowledge Sickness ratio: 0.0012% Susceptible population: the age of onset is the highest in 30~60 years old Mode of infection: mosquito bites Complications: anemia
Cause
Celiac disease
Parasitic infection factors (70%):
Most of them are caused by filariasis. Nowadays, common complications of urinary tract filariasis can occur in the acute phase and chronic phase. Domestic data prove that malaria filariasis can also have chyluria and hydrocele. , scrotum and other scrotal complications, but very few.
Disease factor (10%):
Obstruction of the thoracic duct, local lymphatic inflammation, resulting in changes in lymphatic dynamics. Such as tuberculosis, malignant tumors and other widespread violations of the retroperitoneal lymphatic vessels, lymph nodes, causing damage or obstruction, is rare.
Pathogenesis:
The filariasis is transmitted by Culex pipiens pallens and Culex pipiens pallens; the vector of Malay worm is Anopheles sinensis and Anopheles sinensis, etc. After mosquito bites or insects, the microfilariae in human blood are paralyzed. Inhaled into the stomach, the microfilariae are removed from the outer sheath of the mosquito, and developed into infected larvae through the sausage period and twice peeling. When the mosquito bites a healthy human body, the infectious larva enters the subcutaneous tissue from the skin wound and Lymphatic vessels, and migrate to the large lymphatic vessels, lymphatic stems, grow and develop into adults, adult mature in the human body, after mating, produce microfilariae and enter the blood circulation, and then bite by mosquitoes, develop into infectious larvae in mosquitoes And spread by mosquitoes to others.
Regarding the pathogenesis, a secretory theory has been proposed before, and it is believed that the urinary fat droplets are caused by the special secretion of the kidney. Later, it was proved that this fat droplet is the chylomicron in the lymph, thus denying the secretion theory.
In 1862, Carter proposed that the chyluria was caused by extensive varicose lymphatic rupture and lymphatic flow into the urinary system. In 1863, Ackerman believed that the chyluria was due to the lymphatic trunk, especially the obstruction of the thoracic duct, and the lymphatic regurgitation in the intestinal trunk was ruptured. Since the lymphatics entered the urinary tract, the Ackerman-Carter theory has been dominant until the 1970s. Many scholars in China have done a lot of research on the pathology and pathophysiology of chyluria since the early 1950s. In clinical studies, it was found that the thoracic duct of patients with chyluria was unobstructed, thus negating Ackerman-Carter's theory of thoracic duct obstruction and the late aortic dissection of the axillary lymphatics.
Peng Yiping used lymphangiography to find that there was renal parenchymal lymphatic reflux in patients with chyluria, and the contrast agent could rise across the midline along the waist and show renal parenchymal reflux. Liu Shiyi et al performed preoperative, middle and posterior retroperitoneal surgery on patients with chyluria. Lymphangiography, it is believed that the urinary urinary system is caused by mechanical and inflammatory damage caused by filarial parasitic in the human retroperitoneal lymphatic system, causing destruction of lymphatic vessels and their valves, extensive lymphatic vessels, relative valve insufficiency, lymph fluid Drainage delay, reflux, and effusion through the rupture of the kidney nipple mixed with urine, is the result of fluid fluid dynamics changes, Xie Tong et al also through lymphangiography, the lymphatic system dynamics change is This is the main reason for the formation of chyluria.
Lu Gongcheng and other applications of TV lymphography technology to dynamically observe the changes in the retroperitoneal lymphatic system of urinary fistula patients and dogs with ligation of the thoracic duct, pointing out:
1 TV lymphography diagnosis of direct and indirect specific signs of chyluria has renal pedicle lymphatic display and intrarenal lymphatic network display.
2 Anatomically, the thoracic duct is less than the valve below the chest 5, and the thoracic duct is located between the esophagus and the semi-singular vein at the level of the chest 4 to 5 and then turns to the left edge of the esophagus. Therefore, in the lymphography, the thoracic duct portion below the chest 5 Displayed or not shown, the above is continuously displayed, and the development of the thoracic duct is also related to the amount of contrast agent, and it cannot be shown by the chest catheter or not as evidence of chest tube obstruction in patients with chyluria.
3 The initiating factor of lymphatic pathological changes is obstruction. In animal experiments, after the ligament of the thoracic duct of the dog is ligated, the abdominal lymphatic vessels are widely expanded and proliferated.
4 simple obstruction does not necessarily cause chyluria, after ligation of the dog's thoracic duct, the distal lymphatic vessels expand, proliferate, collateral circulation is established, the obstruction can be recanalized.
5 The increase in lymphatic flow does not cause chyluria.
6 The human thoracic duct has a lateral side path, and there is a lymphatic venous anastomosis when it is normal. Therefore, after a certain part of the thoracic duct is blocked, due to the opening of the lateral side path and/or the lymphatic vein passage, there is generally no serious obstruction, and the chest is ligated. The catheter can be used to treat thoracic duct injury or chylothorax. This group of experimental animals ligated the thoracic duct without chyluria.
In summary, according to animal experiments and clinical research results, Lu Gongcheng and other believe that: the key factors in the pathogenesis of chyluria may not be simple thoracic duct obstruction, simple lymphatic flow and lymphatic pressure, simple lymphatic vessel expansion and hyperplasia, It is the result of the tension-free expansion of the retroperitoneal lymphatic vessels. The occlusive lymphangitis caused by filarial worms, under the action of lymphatic kinetic factors, the lymphatic vessel motility is enhanced, and the lymphatic circulation is increased. If it is not enough to overcome the obstruction, the lymphatics are Fibrosis occurs in the wall of the tube, extensive tension-free expansion of the lymphatic vessels, destruction of the valve in the tube, insufficiency of function, stasis of lymphatic fluid, elevation of lymphatic vessels, and rupture in the weak part, such as rupture in the chest, forming a chylothorax In the abdominal cavity, the chyle is formed; in the urinary tract, chyluria is formed due to rupture of the capillary lymphatic vessels in the kidney, and the lymphatic vessels in the renal humerus are extremely fragile, so the chyle is far more nipple than the chylothorax, and the chyle is more.
Prevention
Chyluria prevention
(1) Anti-mosquito and mosquito killing
Cut off the means of transmission and eliminate mosquito breeding grounds. It is best to use mosquito nets during the mosquito season; when working outdoors, pay attention to the skin on the exposed parts such as anti-mosquito oil, mosquito repellent and other repellents. The head can be impregnated with 701 anti-mosquito net made of cotton. .
(2) census
In the summer, a census of people over 1 year old in the epidemic area requires more than 95% of the residents to receive blood collection; early detection of patients and worms, timely cure, not only to ensure the health of the people, but also to reduce and eliminate the source of infection. In the winter, the microfilariae-positive or microfilaria-negative but with a history and signs of filariasis were treated.
(3) Epidemiological surveillance
Strengthen epidemiological surveillance of areas where basic filariasis indicators have been eliminated. Pay attention to the monitoring work:
1Review and re-examine the original positive patients; re-investigate and repair the unexamined patients; strengthen the management of the floating population, find the patients, and treat them in time until they turn negative.
2 Strengthen the mosquito-borne surveillance of blood-positive households and find that infected mosquitoes, that is, focus on infected mosquitoes, expand blood tests and kill mosquitoes to surrounding people to remove epidemic spots and prevent further spread.
(4) Protect susceptible populations
In the endemic areas, the sea group raw salt therapy is used. Each kilogram of salt is mixed with seaweed 3g, with an average of 16.7g of salt per person per day, containing 50mg of sea group, which can reduce the positive rate of microfilaria in the population.
Complication
Celiac urinary complications Complications anemia
Urination disorders, weight loss, fatigue edema.
Symptom
Chyluria symptoms common symptoms dull pain, fatigue, edema, weight loss
Patients often have a history of filariasis endemic areas or a history of filaria infection, urine is milky white or soy sauce color, or mixed with chyle clots, floating lipid drops after standing, mostly intermittent, severe cases can be persistent Each time lasts for several days or weeks, often due to high-fat diet, tired, induced or aggravated after cooling, unilateral or bilateral low back soreness or dull pain, sometimes due to chyle block and blood clot obstruction of the ureter Colic; if the urethra is blocked, dysuria or urinary retention may occur, and long-term recurrent chyluria may cause malnutrition such as fatigue, weight loss, edema, and anemia.
Examine
Chyluria examination
1. Urine examination: After standing in a glass container, the urine can be divided into 3 layers: the upper layer is white lipid, the middle layer is chyle, the bottom layer is red, white blood cells, urine protein is positive, urine urinary sputum test is positive (urine specimen is added The turbidity disappeared after the ether, and there was an fat ring after centrifugation. The microfilaria in the urine was positive.
2. Blood examination: microfilaria can be found at night, and the white blood cell count is increased in the acute phase, and eosinophils are also significantly increased.
3. Cystoscopy: sputum patients 2 to 3 hours before the entrance into high-fat foods, such as fried poached eggs, heavy oil fried rice, etc., and strengthen the activity, to see when the urine is milky white immediately to check to see the urinary tract from which the ureter The mouth is squirted. In addition, retrograde ureteral intubation can be performed to collect renal pelvis for microscopic examination and chyle test. Obvious renal pelvic regurgitation can be seen during retrograde pyelography.
4. Lymphatic angiography: The location, number and extent of pathological traffic between lymphatic and urinary tract can be displayed. Usually, the posterior lymphangiography of the foot is used. In normal lymphography, there is no contrast agent in the renal area. The affected side of the chyluria patient can be It shows the distorted and dilated lymphatic vessels of the renal pedicle, showing the contour of the renal pelvis and renal pelvis; the thickness of the retroperitoneal lymphatic vessels is uneven, even bamboo-like, and the lymph nodes may have filling defects.
Diagnosis
Diagnosis and diagnosis of chyluria
diagnosis
According to the history of filariasis, scrotal lymphedema and other parts of filariasis in the epidemic area of filariasis, the detection of fat globules in urine is the basis for the diagnosis of chyluria.
Differential diagnosis
1. Pyuria: When there is pyuria in the genitourinary infection, the urine is milky white and turbid, even with pus, and the surface resembles chyluria. However, patients with pyuria often have a history of urogenital infection, and there are obvious urinary tract irritation, urine routine. A large number of pus cells and white blood cells were observed. After the urine was left, there was no floating lipid drop, and the urine chyle test was negative. At the same time, the urine bacterial culture count was >105/ml.
2. Crystalline urine: the urine is clearer when it is discharged, and it is milky white and turbid after standing. These patients often have no urinary system symptoms. Urine microscopic examination shows more crystals, with oxalate, urate, phosphate. Mainly, after the urine was left, there was no floating fat drop, and the chyle test was negative.
3. Proteinuria: When the protein content in the urine is high, it may be cloudy and foamy, but such patients often have an acute, chronic kidney disease history, accompanied by edema, hypertension and other symptoms, urine sediment microscopic examination shows many red, White blood cells and casts, 24h urine protein quantitation is 1.0 ~ 3.5g.
4. Chronic prostatitis: milky white mucus overflows from the urethra at the beginning or end of urination, and can make the urine become turbid. These patients are often accompanied by frequent urination, urethral tingling, lower abdomen, perineum, waist and testicles. Swelling discomfort, sexual dysfunction and other symptoms, rectal examination showed prostate toughness, mild tenderness, routine examination of prostatic fluid can be found in a large number of pus, white blood cells, lecithin bodies reduced or disappeared.
