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LymphoedemaAre Investigations Necessary ?
Usually Clinical history and examinations is enough
diagnosis of lymphoedema In typical, mild swellings with no complications,
No Need for investigations
In atypical & Multifactorial Swelling
Help to confirm Inform management
Provide prognostic information
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Routine Tests
Full blood count
Blood Sugar level
Urea and electrolytes Creatinine
Liver, thyroid function tests
Chest x-ray
Urine dipstick (chyluria)
Blood smear (microfilaria)
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Direct Lymphangiography In this technique,the lymphatics of the lower limb are
delineated with radio opaque dye and there issubsequent radiographic visualization of the vesselsand nodes .
Surgically the lymphatic trunk of the dorsum of thefoot is exposed and iodized oil contrast medium
(neohydriol ultra fluid lipiodol) is injected directly into the trunk.
For lower limb approximately 6 ml of solution isinjected over a period of 1 hour
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Direct LymphangiographyComplications
Surgical exposure Damage to the lymphatic endothelium by oil
Pulmonary oil embolism
Wound infection
Respiratory distress
Used in Few Cases
Preoperative MegaLymphatics considered forbypass or fistula ligation
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Lymphangiographic patterns of primary lymphedema
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lymphangiographic
image depicts rarefaction(reduced lymphnodes inthe left groin.)
normal lymphatic
drainage pattern right legdecreased lymphatics
only one ectactic lymphvessel
physiological venousenhancement
Lymphoedema of left leg
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Indirect Lymphangiography Indirect lymphangiography involves the intradermal
injection of water-soluble, non-ionic contrast into aweb space, from where it is taken up by lymphaticsand then followed radiographically,
Iotrolan or Iotasol is infused by a motor pump into theskin; 2-3ml injected intradermally, Dermal andsubcutaneous collecting lymphatics can be visualized
In the presence of incompetent valves and dermal backflow,(proximal obliteration) lymphatic capillaries
can be seen
It shows distal lymphatics but not normally proximal
lymphatics and nodes
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Contrast materialinjected into a
web space
Subcutaneous lymphatics
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Isotope lymphoscintigraphy It has replaced lymphangiography and is the Gold
Standard Now.
Radioactive technetium-labelled protein or colloid
particles are injected into an interdigital web spacebetween 2ndand 3rdtoes or fingers. limb is exercisedperiodically and images are taken using a gammacamera.
provides insight into lymph flow dynamics. helps evaluate lymphatic truncal anatomy and
radiotracer transport.
The procedure can easily be repeated, and does notadversely affect the lymphatic vascular endothelium.
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Isotope lymphoscintigraphy
Clearance time is calculated from the regions oflymphatics, over the nodes & it gives us the
quantitativeanalysis of lymphatic system
Peripheral lymphatics is grossly impaired inlymphedema, with hypoplastic distal lymph vessels
This gives a characteristic picture at the injection siteand virtually no clearance of the tracer
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39-year-old woman with right
leg lymphedema
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Congenital lymphedema of
the left arm in a 3-year-old girl
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CT scan (CT) slice through the midcalf has been proposed as a
useful diagnostic test for
lymphoedema(coarse, non-enhancing, reticularhoneycomb pattern in an enlarged subcutaneouscompartment),
Venous oedema (increased volume of the muscular
compartment) and lipoedema(increased subcutaneous fat).
CT can also be used to exclude pelvic or abdominalmass lesions.
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Primary lymphedema of the left
leg in a 42-year-old woman
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MRI Magnetic resonance Imaging
Clear Images of lymphatic Channels and lymph nodes
Useful in assessment of patients with lymphatic
hyperplasia Distinguish between Venous and lymphatic causes of a
swollen limb.
shows tumours causing obstructions
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Transaxial MRI:Chylousreflux syndrome in a 12-year-old boy.
prominent perirectallymphatic vessels
pubic skin withsuperficiallymphangiectasia
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Ultrasound Ultrasound can provide useful information about
venous function, including DVT and venousabnormalities
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Pathological Examination
Where Malignancy is suspected Lymph node biopsy obtained by fine-needle
aspiration, needle core biopsy or surgical excision.
Skin Biopsy where lymphangiosarcoma is suspected
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Lymph node enlargement Blood: blood examination is essential for leucocytosis (acute
lymphadenitis),TB,lymphatic leukemia,raised ESR inlymphosarcoma.
Aspiration: of cold abcess:acid fast bacilli or lymphogranulomainguinale:0.1 ml of diluted pus when injected intradermally a
reddish papule appear within 48 hrs. FREIs intradermal test. Mantouxtest for tuberculosis
Gordonsbiological test:hodgkins
Biopsy
Radiological:To look for enlargement of LN
Laprotomy:Hodgkins,to know the clinical staging of the disease.It involves a wedge biopsy of liver, aortic,mesentric iliacLNbiopsy ;chip biopsy of iliac bone & splenectomy.
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Burkitts lymphoma
Biopsy LN reveals atypical starry skyappreance ofprimitive lymphoid
cells with large clearhistiocytes
Burkitt cell --containingintracytoplasmic lipid
droplets
Stars
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Syphilitic lymphadenitis
W.R and Khan testusually positive
Treponema pallidum may be demonstrated inspecimens obtained from genital and mucocutaneouslesion in dark ground illumination microscopy.
Specific tests: treponemal antigen test Treponemal haemagglutination assay
Treponema pallidum immobilization test.
Filarial lymphadenitis Lymphangiogram for lymphangiectasis
Blood pictureeosinophilia,microfilariademonstrated in blood drawn at night
Biopsy L.N reveal adult filaria
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Lymphangiogram
demonstrating lymphatic
reflux from dilated para-
aortic vessels into the left
kidney in a patient with
filariasiswho
presented with chyluria.
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