小動物疾病系統

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乳糜胸
作者
陳柏達、賴政宏、鄭豐邦
中文病名 乳糜胸
英文病名 Chylothorax
疾病描述

 病因:

    乳糜胸定義為乳糜液積聚於胸腔內。乳糜液是由淋巴液及三酸甘油酯的小滴所構成,富含淋巴球、蛋白質、可溶性脂質及維他命,而乳糜胸之乳糜液的來源即由腸管淋巴匯集至胸管,過程中乳糜液被滲漏至胸腔所導致。

    滲漏的原因大致分三種:先天性(較少見)、創傷性(較少見)、非創傷性(較多見)。先天性的原因可以是生理結構上的異常,如胸管的先天性異常,或是其他先天性的疾病所造成。創傷性的原因又可細分為手術性創傷,如開胸手術;以及非手術性創傷,如車禍撞擊。非創傷性的原因則有許多種,包含造成淋巴液流通阻塞的腫瘤,如貓的縱隔淋巴瘤;靜脈栓塞、靜脈高壓亦會成淋巴液流通阻塞;全身性淋巴管擴張、發炎;心肌病、心絲蟲症、心包疾病或是其他導致右心衰竭的疾病;肺葉扭轉;橫膈赫尼亞(疝脫)等。

    好發年齡可於犬、貓的任何年齡。好發品種又以阿富汗獵犬(Afghan Hounds)及柴犬(Shiba Inus)較為常見。

臨床症狀:

    由於胸腔乳糜液蓄積所造成的呼吸困難是最典型臨床症狀,雖然呼吸困難常常是急性發生的,但事實上有許多細微的病徵是已經潛在存在數個月以上的,如嗜睡、厭食、體重減經、運動不耐等;在某些病例中,咳嗽也可能是唯一存在的臨床症狀。

診斷方法

 1.          胸腔放射線影像學檢查。

2.          胸腔穿刺,抽取乳糜液以進行細胞學檢查及生化分析。

3.          血液全血球檢查可能有出現低淋巴球血症及低蛋白血症。

  一旦乳糜胸確診後,尚可進行其他相關檢測:心臟超音波檢查、心電圖檢查、心絲蟲檢測、甲狀腺激素濃度檢測(特別是貓)、淋巴管造影(確認淋巴管是否擴張及淋巴管阻塞位置,偶而可見胸管滲漏位置)等。

治療方法

 胸腔穿刺抽取胸水,以及提供適當的輸液治療可以減緩並穩定患畜乳糜胸的情況,但是要深入了解鑑別診斷出乳糜胸潛在的病因,並有效的解決其原因才會是真正解決乳糜胸的治療方法。

    如果是不明原因的乳糜胸情況,一般常規的治療方式由保守至積極大致分為三階段, 由於不明原因的乳糜胸在部分病例中仍有自癒的情況,所以治療上也都建議由保守至積極,尋進漸進進行。

    第一階段治療,是間歇性胸腔穿刺和低脂飲食。胸腔穿刺的時機在於畜主確實觀察到患畜有明顯呼吸窘迫,食慾、活動力下降等影響生活品質及安全的情況下,以每1-2周進行一次胸腔穿刺,治療後期會隨著乳糜胸情況的改善逐漸拉長胸腔穿刺的間隔時間。低脂飲食的治療效用雖然目前仍然有待商確,但多數病例中皆有得到好的治療結果,需要注意的是,雖然採用低飲食,但仍要保持營養的均衡性跟全面性,以維持患畜的健康。在此階段,尚可以搭配服用芸香素(rutin),一種酚酮類配糖體,在人醫領域此藥物被用來治療淋巴水腫,該要藥物可以藉由影響巨噬細胞功能達到減少滲出胸液的蛋白濃度,進而提高將滲出胸液再吸收的效率。其建議的劑量為50-100 mg/kg,每8小時口服一次。

    第二階段治療,其時機在於第一階段治療執行後1-3個月仍無有效改善,或是患畜的臨床症狀本身已經嚴重至無法忍受情形,則建議採取外科手術治療。外科手術主要為胸管結紮(thoracic duct ligation),可搭配實施心包囊切除術(pericardectomy)或乳糜池摘除(ablation of the cisterna chyli)胸管結紮為一難度較高的術式,需要將胸管及其附屬分支皆確實進行結紮,往往會搭配使用淋巴管影像造影旯提高其成功率。心包囊切除術心包囊切除術可減緩靜脈高壓,可提高手術成功。乳糜池摘除亦有研究指出可提高手術成功率。

    第三階段治療,其時機在於第一、二階段治療執行後仍無有效改善時,則以外科手術方式裝置胸-腹腔或胸腔-靜脈分流管(pleuroperitoneal or pleurovenous shunts)、橫膈膜濾網(mesh within the diaphragm),創造出能使乳糜液排出胸腔的路徑,以減少乳糜液造成肺臟壓迫,減緩的呼吸窘迫的情形。但此裝置的缺點是,往往在術後的幾個月內,其排流的功能會逐漸下降。

預防控制方法

 間歇性胸腔穿刺及低脂飲食。

相關圖片 <p>&nbsp;放射線影像學檢查。</p>
<div>圖片說明:於胸腔腹背照下,可見雙側肋膜腔處之軟組織不透明度影像,左側範圍較右側小。肺葉邊緣鈍圓 (rounding),肺臟不透明度上升,可見肺葉呈扇形(scalloping),右側前葉、中葉、後葉之肺葉間隙加深 &nbsp;(widened of the interlobular fissure),左肺前葉後葉間亦有此現象。軟組織不透明度影像使雙側肺臟的臟層肋膜表面遠離胸壁及橫膈表面,產生肺臟內縮的現象(lung retraction)及肺臟膨脹不全 (underinflation),右側較為明顯。軟組織不透明度產生之邊界遮蔽效應 (border effacement),使心臟輪廓模糊及橫膈邊緣消失,綜合上述結果,此軟組織不透明度影像為肋膜腔積液。</div>
<div>&nbsp;</div>
Close<p>&nbsp;放射線影像學檢查。</p>
<div>圖片說明:於胸腔腹背照下,可見雙側肋膜腔處之軟組織不透明度影像,左側範圍較右側小。肺葉邊緣鈍圓 (rounding),肺臟不透明度上升,可見肺葉呈扇形(scalloping),右側前葉、中葉、後葉之肺葉間隙加深 &nbsp;(widened of the interlobular fissure),左肺前葉後葉間亦有此現象。軟組織不透明度影像使雙側肺臟的臟層肋膜表面遠離胸壁及橫膈表面,產生肺臟內縮的現象(lung retraction)及肺臟膨脹不全 (underinflation),右側較為明顯。軟組織不透明度產生之邊界遮蔽效應 (border effacement),使心臟輪廓模糊及橫膈邊緣消失,綜合上述結果,此軟組織不透明度影像為肋膜腔積液。</div>
<div>&nbsp;</div>

<p>&nbsp;放射線影像學檢查。</p> <div>圖片說明:於胸腔腹背照下,可見雙側肋膜腔處之軟組織不透明度影像,左側範圍較右側小。肺葉邊緣鈍圓 (rounding),肺臟不透明度上升,可見肺葉呈扇形(scalloping),右側前葉、中葉、後葉之肺葉間隙加深 &nbsp;(widened of the interlobular fissure),左肺前葉後葉間亦有此現象。軟組織不透明度影像使雙側肺臟的臟層肋膜表面遠離胸壁及橫膈表面,產生肺臟內縮的現象(lung retraction)及肺臟膨脹不全 (underinflation),右側較為明顯。軟組織不透明度產生之邊界遮蔽效應 (border effacement),使心臟輪廓模糊及橫膈邊緣消失,綜合上述結果,此軟組織不透明度影像為肋膜腔積液。</div> <div>&nbsp;</div>


<p>&nbsp;<b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">經胸腔穿刺抽取之肋膜腔液體。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:肋膜腔液體呈現乳白色外觀。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>
Close<p>&nbsp;<b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">經胸腔穿刺抽取之肋膜腔液體。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:肋膜腔液體呈現乳白色外觀。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>

<p>&nbsp;<b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;">經胸腔穿刺抽取之肋膜腔液體。</span></b></p> <p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:肋膜腔液體呈現乳白色外觀。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"><o:p></o:p></span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">肋膜腔液體分析之細胞學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(Diff-Quik, 1000</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:採樣樣本可見以小型淋巴球、嗜中性球及巨噬細胞為主,部分嗜中性球具退行性變化</span><span lang="EN-US" style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體;mso-font-kerning:1.0pt;mso-ansi-language:EN-US;
mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA"> (degenerative change)</span><span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:
&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language:
ZH-TW;mso-bidi-language:AR-SA">。</span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">肋膜腔液體分析之細胞學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(Diff-Quik, 1000</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:採樣樣本可見以小型淋巴球、嗜中性球及巨噬細胞為主,部分嗜中性球具退行性變化</span><span lang="EN-US" style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體;mso-font-kerning:1.0pt;mso-ansi-language:EN-US;
mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA"> (degenerative change)</span><span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:
&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language:
ZH-TW;mso-bidi-language:AR-SA">。</span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖三、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">肋膜腔液體分析之細胞學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(Diff-Quik, 1000</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br /> <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;; mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language: EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:採樣樣本可見以小型淋巴球、嗜中性球及巨噬細胞為主,部分嗜中性球具退行性變化</span><span lang="EN-US" style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體;mso-font-kerning:1.0pt;mso-ansi-language:EN-US; mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA"> (degenerative change)</span><span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;mso-ascii-font-family: &quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family: &quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:EN-US;mso-fareast-language: ZH-TW;mso-bidi-language:AR-SA">。</span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><span style="font-family: 標楷體;">患犬將進行胸管結紮及部分心包囊切除</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> (thoracic duct ligation and subtotal pericardectomy)</span><b><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:此圖為術前進行的淋巴造影</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> (Lymphangiography)</span><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">,於膝膕淋巴結內注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> Omnipaque &reg; 300 mg I/mL </span><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之有機碘,依</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 1 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">之劑量,</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體">2&nbsp; mL/min</span><span style="font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之速率給予。於腹腔右側躺照下,可見股骨遠端</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 1/3</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">後側有一不透明度極高之線性構造,於第</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 6-7 </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">腰椎腹側,腸骨下淋巴結位置聚集,造影劑由脊椎腹側,往頭側及背側延伸,於胸椎之腹側可見胸管之單一管狀結構,胸腔前腹側可見多數小型管狀結構,推測為擴張及彎曲的前縱膈淋巴管,顯影劑由腎臟經輸尿管,於膀胱三角進入膀胱,膀胱頭側可見顯影劑殘留。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><span style="font-family: 標楷體;">患犬將進行胸管結紮及部分心包囊切除</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> (thoracic duct ligation and subtotal pericardectomy)</span><b><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:此圖為術前進行的淋巴造影</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> (Lymphangiography)</span><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">,於膝膕淋巴結內注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> Omnipaque &reg; 300 mg I/mL </span><span style="font-family:標楷體;mso-ascii-font-family:
&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之有機碘,依</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 1 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">之劑量,</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體">2&nbsp; mL/min</span><span style="font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之速率給予。於腹腔右側躺照下,可見股骨遠端</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 1/3</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">後側有一不透明度極高之線性構造,於第</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 6-7 </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">腰椎腹側,腸骨下淋巴結位置聚集,造影劑由脊椎腹側,往頭側及背側延伸,於胸椎之腹側可見胸管之單一管狀結構,胸腔前腹側可見多數小型管狀結構,推測為擴張及彎曲的前縱膈淋巴管,顯影劑由腎臟經輸尿管,於膀胱三角進入膀胱,膀胱頭側可見顯影劑殘留。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖四、</span></b><span style="font-family: 標楷體;">患犬將進行胸管結紮及部分心包囊切除</span><span lang="EN-US" style="font-family: 'Times New Roman', serif;"> (thoracic duct ligation and subtotal pericardectomy)</span><b><span style="font-family:標楷體;mso-ascii-font-family: &quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b></p> <p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:此圖為術前進行的淋巴造影</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> (Lymphangiography)</span><span style="font-family:標楷體;mso-ascii-font-family: &quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">,於膝膕淋巴結內注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> Omnipaque &reg; 300 mg I/mL </span><span style="font-family:標楷體;mso-ascii-font-family: &quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之有機碘,依</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> 1 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">之劑量,</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體">2&nbsp; mL/min</span><span style="font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;">之速率給予。於腹腔右側躺照下,可見股骨遠端</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> 1/3</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">後側有一不透明度極高之線性構造,於第</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> 6-7 </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">腰椎腹側,腸骨下淋巴結位置聚集,造影劑由脊椎腹側,往頭側及背側延伸,於胸椎之腹側可見胸管之單一管狀結構,胸腔前腹側可見多數小型管狀結構,推測為擴張及彎曲的前縱膈淋巴管,顯影劑由腎臟經輸尿管,於膀胱三角進入膀胱,膀胱頭側可見顯影劑殘留。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"><o:p></o:p></span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">患犬正在進行胸管結紮及部分心包囊切除</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> (thoracic duct ligation and subtotal pericardectomy)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:移除大動脈上的胸膜,未見胸管之影像,遂鈍剝膝膕淋巴結,以</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 27 G </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">蝴蝶針於膝膕淋巴結注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體"> 1 %</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">甲基藍溶液</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> (10 mg/mL) 0.05 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">以輔助確認胸管位置。此圖可見主動脈背側有一淡紫色管狀結構,確認為胸管後以血管夾</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體">&nbsp; (vascular clip)</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">將其結紮,完成胸管結紮後以潤濕之紗布塊覆蓋於術區。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">患犬正在進行胸管結紮及部分心包囊切除</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> (thoracic duct ligation and subtotal pericardectomy)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">。</span></b></p>
<p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:移除大動脈上的胸膜,未見胸管之影像,遂鈍剝膝膕淋巴結,以</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體"> 27 G </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">蝴蝶針於膝膕淋巴結注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體"> 1 %</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">甲基藍溶液</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> (10 mg/mL) 0.05 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">以輔助確認胸管位置。此圖可見主動脈背側有一淡紫色管狀結構,確認為胸管後以血管夾</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體">&nbsp; (vascular clip)</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:
&quot;Times New Roman&quot;">將其結紮,完成胸管結紮後以潤濕之紗布塊覆蓋於術區。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"><o:p></o:p></span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖五、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">患犬正在進行胸管結紮及部分心包囊切除</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"> (thoracic duct ligation and subtotal pericardectomy)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;">。</span></b></p> <p class="MsoNormal"><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖片說明:移除大動脈上的胸膜,未見胸管之影像,遂鈍剝膝膕淋巴結,以</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體"> 27 G </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">蝴蝶針於膝膕淋巴結注射</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:標楷體"> 1 %</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;">甲基藍溶液</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"> (10 mg/mL) 0.05 mL/kg </span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;">以輔助確認胸管位置。此圖可見主動脈背側有一淡紫色管狀結構,確認為胸管後以血管夾</span><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體">&nbsp; (vascular clip)</span><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family: &quot;Times New Roman&quot;">將其結紮,完成胸管結紮後以潤濕之紗布塊覆蓋於術區。</span><span lang="EN-US" style="mso-bidi-font-size:12.0pt;font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"><o:p></o:p></span></p>


<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖六、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">將術中切除之心包膜組織進行組織病理學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(H&amp;E stain, 200</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:低倍可見心包膜多發出血,單核炎症細胞圍繞血管旁浸潤,並可見數個大小不一結節樣團塊,團塊周圍有纖維結締組織增生包被,中心為壞死灶、膽固醇裂隙及炎症浸潤,且可見鈣化灶,淋巴管內亦可見膽固醇裂隙。</span></p>
Close<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">圖六、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">將術中切除之心包膜組織進行組織病理學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(H&amp;E stain, 200</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;
mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family:
標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;;
mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br />
<span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體;
mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;;
mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language:
EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:低倍可見心包膜多發出血,單核炎症細胞圍繞血管旁浸潤,並可見數個大小不一結節樣團塊,團塊周圍有纖維結締組織增生包被,中心為壞死灶、膽固醇裂隙及炎症浸潤,且可見鈣化灶,淋巴管內亦可見膽固醇裂隙。</span></p>

<p>&nbsp;<b><span style="mso-bidi-font-size:12.0pt;font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">圖六、</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">將術中切除之心包膜組織進行組織病理學檢查</span></b><b><span style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體"> </span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體;mso-font-kerning:0pt;mso-no-proof:yes">(H&amp;E stain, 200</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;; mso-fareast-font-family:標楷體">X</span></b><b><span lang="EN-US" style="font-family:&quot;Times New Roman&quot;,&quot;serif&quot;;mso-fareast-font-family: 標楷體;mso-font-kerning:0pt;mso-no-proof:yes">)</span></b><b><span style="font-family:標楷體;mso-ascii-font-family:&quot;Times New Roman&quot;; mso-hansi-font-family:&quot;Times New Roman&quot;">。</span></b><br /> <span style="font-size:12.0pt;mso-bidi-font-size:11.0pt;font-family:標楷體; mso-ascii-font-family:&quot;Times New Roman&quot;;mso-hansi-font-family:&quot;Times New Roman&quot;; mso-bidi-font-family:&quot;Times New Roman&quot;;mso-font-kerning:1.0pt;mso-ansi-language: EN-US;mso-fareast-language:ZH-TW;mso-bidi-language:AR-SA">圖片說明:低倍可見心包膜多發出血,單核炎症細胞圍繞血管旁浸潤,並可見數個大小不一結節樣團塊,團塊周圍有纖維結締組織增生包被,中心為壞死灶、膽固醇裂隙及炎症浸潤,且可見鈣化灶,淋巴管內亦可見膽固醇裂隙。</span></p>


參考文獻

 1.          Hawkins EC, Disorders of the pleural cavity. In: Nelson RW, Couto CG. Small Animal Internal Medicine, 5th ed, Elsevier Mosby, Missouri, 352-353, 2014.

2.          MacPhail CM, Pleural and mediastinal disorders. In: Fuentes VL, Johnson L, Dennis S. BSAVA manual of canine and feline cardiorespiratory medicine, 2nd ed. BSAVA, UK, 299, 2010.

3.          Frame M, King A. The pleural space. In: Schwarz T, Johnson V, BSAVA  manual of small animal thoracic imaging. BSAVA, UK, 332, 2008.

4.          圖片來源:

國立中興大學教學動物醫院民國101年臨床病例報告。

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