investigations of lymphatics.ppt

8/10/2019 investigations of lymphatics.ppt

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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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investigations of lymphatics.ppt