6. Lymphangitis - Lymphoedema.pdf

Lymphangitis & Lymphoedema Prof. U.Murali. Learning Objectives • Outline the Surgical anatomy & Functions of Lymphatic system. • List out the various causes of limb swelling. • Write a note on – Lymphangitis. • Define and Classify lymphoedema. • Outline the risk factors & pathophysiology of lymph...

Lymphangitis & Lymphoedema Prof. U.Murali. Learning Objectives • Outline the Surgical anatomy & Functions of Lymphatic system. • List out the various causes of limb swelling. • Write a note on – Lymphangitis. • Define and Classify lymphoedema. • Outline the risk factors & pathophysiology of lymphoedema. • Describe the aetio-pathogenesis, C/F, D/D, complications, investigations and treatment of lymphoedema. Surgical Anatomy • Lymphatic system – comprises - Lymphatic channels, lymphoid organs & circulating elements (lymphocytes & other mononuclear immune cells). • Lymphatic capillaries – smallest lymph vessel first to receive lymph. • Lymphatic collecting vessels – collect from lymph capillaries. • Lymph nodes – scattered along collecting vessels. • Lymph trunk – collects from lymph nodes & collecting vessels. • Lymph ducts – empty into veins of the neck. Surgical Anatomy • Lymph from the LUL, LL, & Abd - Drain via the CC → TD, which in turn → LIJV at its confluence with the LSCV. • Lymph from the head [rt] and right arm drains via a separate lymphatic trunk, RLD → RIJV. Functions of Lymphatics • Return of protein rich fluid to the circulation through the L V Junctions. • Water, electrolytes and macromolecules (fibrinogen, albumin globulins, coagulation and fibrinolytic factors) from the interstitial fluid (ISF) return to the circulation via the lymphatics. • Intestinal lymph (chyle) transports cholesterol, long-chain fatty acids and fat-soluble vitamins directly to the circulation, by passing the liver. • 8L – lymph produced daily. Once it reaches LN – conc. to 4L – which enters the venous circulation. * Non-vascular •Gen.Dis.states - CCF - Liver failure -Hypoproteinaemia - Hypothyroidism - Immobility - LL - dependency • Loc.Dis.processes - Tumours - Haematoma - Cellulitis - Ortho lesions Exam Non-vascular • Gigantism • R P - fibrosis • Drugs • Trauma • Obesity Venous •DVT • Simple V Vein • Postthrombotic syndrome • Ext. venous compression Arterial •AV - malformation • Aneurysm * OSPE Lymphangitis • Acute inflamm. of lymphatics – Strep pyogenes & Stap aureus. • Precipitating factors: Minor trauma + Lymphoedema. * OSPE • Features: Diffuse swelling with redness + Blanches on pressure is typical. Fever, chills & pain. Regional lymph nodes can get infected and enlarged. • D/D: Cellulitis / DVT. • Investigations: TC / RBS / Venous Doppler. • Treatment: Antibiotics / Limb Elevation / NSAID’s / LA – Glycerine MgSO4. Lymphedema – Definition • It may be defined as abnormal limb swelling due to accum. of fluid (lymph) in ECF & EVF compartment secondary to defective lymphatic drainage. • It is increased protein rich interstitial fluid. L E – Sites │Classification • Lower Limb – Common. • Upper limb. • Scrotum / Penis. • Breast. • Labia / Eyelid. • Localised – Some areas. • Mild - < 20% of excess limb volume. • Moderate – 20 – 40%. • Severe - > 40%. Lymphoedema – Etiological Classification Primary – Cause is unknown/unproven/uncertain * MCQ Lymphoedema – Secondary Most common form – “RARE MIST” • Radiotherapy – LN • Advanced Malignancy – Metastatic spread • Rare causes – DVT / CVI / RA / Snake Bites • Exposure to F B – Material • Malignancy - Primary lymphatic • Infection – P / F / B • Surgical excision of lymph nodes • Trauma (particularly de-gloving injuries) * MEQ L E – Clinical Classification Brunner’s Grading Pathophysiology of L E Infection / Tumour / Surgery ↓ Lymp.contr. / Lymp.val. insuff. / obliteration Lymph stasis + Lympho-tension accum. → proteins/glyco./growth factors /bacteria - ISF ↑Collagen formation + acc.inflm.cells + act.keratinocytes → Protein rich fluid Sub.derm.fibrosis + derm.thickening & proliferation LYMPHOEDEMA Risk Factors - Lymphoedema Upper Limb / Trunk Lower Limb 1. Extensive LN - Surgery Surgery – Inguinal block dissection 2. RT – Axilla PO – RT 3. Complications / Infection Recurrent soft tissue infection 4. Advanced cancer / Obesity / Chronic skin disorders Advanced cancer / Obesity / Chronic skin disorders 5. Congenital predisposition Genetic predisposition / Family history 6. Trauma – injection / venipuncture Orthopedic surgery 7. Living / visiting – endemic area Living / visiting – endemic area Lymphoedema – C / F • Initially pitting edema – later not. • Swelling in foot – ‘Tree trunk pattern’. • Buffalo hump in dorsum of foot. • Squaring of toes. • Stemmer’s sign – Skin over dorsum of foot cannot be pinched. • Constant dull-ache – severe pain. • Eczema, fissuring, papillae (wart) formation, ulceration, elephantiasis are other late features. L E – D / D │Complications • Factitious L E – Hysterical. • Immobility. • Skin thickening / abscess. • Lipoedema – excess deposition of fat – women. • Recurrent cellulitis. • Myxoedema. • Rec. Strept. Infection. • Medical causes. • Maggot’s formation. • Trauma / Tumours. • Venous / Arterial diseases. • Drug induced. • Non-healing ulcers. • Lymphangiosarcoma. Lymphoedema – Investigations • Routine Tests – Identify – Cause. FBC, LFT, TFT • Peripheral smear. • Lymphangiography. • Isotope – lymphoscintigraphy. • U/S / CT – scan / MRI. • FNAC / Perometry. L E – Treatment * MEQ L E – Treatment - Medical 3 Goals – Trt – Pain relief / Reduce swelling / Prevent complications • Pain relief – Suitable means. • Skin Care – Approp. Measures. • Elevation of limb / Wt Reduction. • Exercises – Rhythmic Movements. • Drugs – * Antibiotics – accordingly. * Diuretics – controversial. * Benzopyrones – Lympedim. * Topical applications – accordingly. - contd.. Control of Swelling • Current preferred term – DLT / CDT – 2 phases. • I - intensive phase of therapist-led care. * skin care, MLD & MLLB & exercises. • II- maintenance phase in which the patient uses a self-care regimen with occasional professional intervention. • MLD: Gentle & Simple massage – skin. • I phase: Non-elastic MLLB – preferable. • II phase: Compression graded stockings. L E – Treatment - Surgical Bypass procedures • Omentoplasty • Skin bridge - Gillies • Nodo-venous shunt - Neibulowitz • Ileal mucosal patch - Kinmonth •L V A Liposuction Limb reduction • Chronic L E •Sistrunk • Pts progressed to •Homan’s non-pitting edema. •Thompson •Charle’s L E – Treatment - Surgical Bypass procedures • Omentoplasty • Skin bridge - Gillies • Nodo-venous shunt - Neibulowitz • Ileal mucosal patch - Kinmonth •L V A L E – Treatment - Surgical Bypass procedures • Omentoplasty Liposuction • Chronic L E • Skin bridge - Gillies • Nodo-venous shunt - Neibulowitz • Ileal mucosal patch - Kinmonth •LVA • Pts progressed to non-pitting edema. L E – Treatment - Surgical Limb reduction •Sistrunk •Homan’s •Thompson •Charle’s To Summarize • Surgical anatomy & Functions of Lymphatic system. • Various causes of limb swelling. • Lymphangitis. • Classification of lymphoedema – Pathophysiology. • Clinical features, D/D & Complications – Lymphoedema. • Investigative methods – Lymphoedema. • Medical & Surgical treatment methods of lymphoedema. References Question Time • Define lymphedema. Mention 2 functions of lymphatic system. • List out the various causes of limb swelling. • Classify lymphoedema. • Outline the aetio-pathogenesis of lymphedema. • What are the clinical features of lymphedema? • Write 3 D/D & complications of lymphedema. • List the goals in the medical treatment of lymphoedema and explain them. • Identify the surgical options for lymphedema and name them. A 48-year-old man complains of swelling of his entire lower limb for many years during which time he worked as a farmer in the African continent. He has presented because he developed pain, redness and some discharge from the skin of the affected swollen leg. The most likely diagnosis is – • a) Acute Lymphangitis. • b) Filariasis. • c) Primary Lymphoedema. • d) Secondary Lymphoedema. A 48-year-old man complains of swelling of his entire lower limb for many years during which time he worked as a farmer in the African continent. He has presented because he developed pain, redness and some discharge from the skin of the affected swollen leg. The most likely diagnosis is – • a) Acute Lymphangitis. • b) Filariasis. • c) Primary Lymphoedema. • d) Secondary Lymphoedema. Eleven years after undergoing right modified radical mastectomy, a 61-year-old woman develops raised red and purple nodules over the right arm. What is the most likely diagnosis? • a) Lymphangitis. • b) Metastatic breast cancer. • c) Lymphoedema. • d) Lymphangiosarcoma. Eleven years after undergoing right modified radical mastectomy, a 61-year-old woman develops raised red and purple nodules over the right arm. What is the most likely diagnosis? • a) Lymphangitis. • b) Metastatic breast cancer. • c) Lymphoedema. • d) Lymphangiosarcoma. A familial primary lymphedema with onset below the age of 2 years is – • a) Milroy’s disease. • b) Meige’s disease. • c) Brunner’s disease. • d) Peyer’s disease. A familial primary lymphedema with onset below the age of 2 years is – • a) Milroy’s disease. • b) Meige’s disease. • c) Brunner’s disease. • d) Peyer’s disease. Which of the following investigations is of Least value in the evaluation of disorders of the lymphatic system? – • a) Lymphangiography using contrast. • b) Lymphangiography using isotope. • c) Ultrasonography of lymphatics. • d) MRI of lymphatic channels. Which of the following investigations is of Least value in the evaluation of disorders of the lymphatic system? – • a) Lymphangiography using contrast. • b) Lymphangiography using isotope. • c) Ultrasonography of lymphatics. • d) MRI of lymphatic channels. Which one of the following statements regarding acute lymphangitis is not true? – • a) Erythematous streak is a typical early sign. • b) The commonest organisms causing acute lymphangitis are Pseudomonas and Bacteroides. • c) It might go on to produce lymphoedema. • d) It might result in septicemia. Which one of the following statements regarding acute lymphangitis is not true? – • a) Erythematous streak is a typical early sign. • b) The commonest organisms causing acute lymphangitis are Pseudomonas and Bacteroides. • c) It might go on to produce lymphoedema. • d) It might result in septicemia.