Lymphatic system lymphatic disorder.pptx

Lymphatic disorder

1. LYMPHATIC SYSTEM

2. SURGICAL ANATOMY Primordial lymphatic system begins to develop from 6 th week of development. Peripheral lymphatic system develops from these lymph sacs. Lymph sac has three components- -Terminal lymphatic capillaries -Lymphatic vessels -Lymph nodes Lymph vessels run adjacent to main blood vessels.

3. SURGICAL ANATOMY CONTD.. Cisterna chyli is formed in the abdomen, continues as thoracic duct in the thorax. Thoracic duct has got initial main course towards the rt side of mediastinum but later towards left side entering IJV at its joining point with lt SC vein. Lymphovenous communication occurs at LN level of Iliac, Subclavian and Jugular levels. Lymphatics are absent in epidermis, cornea, CNS, cartilage, tendons and muscles.

4. SURGICAL ANATOMY CONTD.. Great LYMPH DUCTS are- 1. THORACIC DUCT 2. RIGHT LYMPHATIC DUCT 3. SUBCLAVIAL AND JUGULAR TRUNKS 4. BRONCHOMEDIASTINAL TRUNKS THESE CONTAIN VALVES TO PREVENT BACKFLOW.

5. CISTERNA CHYLI Formed by joining of rt and lt lumbar sympathetic trunks and intestinal lymphatic ducts. Lumbar LT are short lymph vessels arising from paraaortic lymph glands and recieves lymph from lower limb, pelvis and pelvic viscera, kidney, adrenals and deep lymphatics of abdominal wall. Intestinal lymphatic ducts arises from preaortic nodes and recieves lymph from stomach, intestines, liver, spleen and pancreas

6. CISTERNA CHYLI CONTD… CC is a lymph sac lying in front of L1 & L2 vertebrae between aorta and crus of the diaphragm. From its upper end it continues as thoracic duct in the chest.

7. THORACIC DUCT Passes through aortic crus of the diaphragm. From there it runs medial to azygos vn and rt of the aorta in the post mediastinum. Related in front to esophagus, diaphragm and pericardium. Behind it is related to IC arteries, hemiazygos and accessory hemiazygos vn. Crosses towards lt side at level of T7 and reaches lt side at level of T5. In the neck it passes in front of vertebral vessels and sympathetic chain and behind carotid system.

8. THORACIC DUCT CONTD.. It ends as a single vessel at the junction of IJV and SCV with a valve. Single termination is common. 45 cm in length and 5 mm in width maximum being at the ends. Tributaries include- 1. Trunk from post mediastinal nodes 2. Lateral IC nodes of upper six spaces 3. Lt jugular lymph trunk 4. From lt upper limb 5. Lt bronchomediastinal trunk.

9. RIGHT LYMPH DUCT About 2.5 cm in length Formed by rt jugular, rt subclavian and rt bronchomediastinal trunks Joins at junction of rt IJV and SCV. About 450-600 LN in the body. -200 in neck -100 in thorax -50-60 in axilla -250 in abd & pelvis -50 in groin

10. LYMPHATIC WATERSHEDS OF SKIN

11. FUNCTIONS OF LYMPHATICS FILTRATION ABSORBTION Cholesterol, long chain fatty acids& fat soluble vitamins are TRANSFERRED through lymphatics into cisterna chyli IMMUNITY

12. INVESTIGATIONS LYMPHANGIOGRAPHY ISOTOPE LYMPHOSCINTIGRAPHY

13. LYMPHANGIOGRAPHY PATENT BLUE DYE OR 1 ML OF ISOSULFAN BLUE IS USED. Radiographs are taken to visualize both lymphatic and LN Secondaries in LN cause filling defect where as lymphoma shows enlarged nodes which have foamy appearance. Not performed these days as it is technically difficult, invasive , time consuming and may not reach the desired area.

14. ISOTOPE LYMPHOSCINTIGRAPHY Radioactive Tc labelled sulphide colloid particles or radioiodinated human albumin is injected into web space which are specifically taken up by lymphatics. Gamma cameras are used to visualize lymphatics and inguinal LN. Radioactivity of inguinal LN is measured at 30 & 60 min In 3 hrs it reaches paraaortic LN, other abdominal LN and liver.

15. ISOTOPE LYMPHOSCINTIGRAPHY More sensitive Technically easier and faster Simple & safe High sensitivity and specificity Thoracic duct, other LN and liver can be imaged.

16. LYMPHEDEMA Accumulation of lymph in extracellular & extravascular fluid compartment commonly in the sub cutaneous tissue. Primarily due to defective lymphatic drainage KINMOTH classified lymphedema as- 1. Primary 2. Secondary

17. PRIMARY LYMPHEDEMA Commonly affects females. Common in lower limbs and on left side It can be- 1. Familial 2. Syndromic (Turner’s, Down’s, Kleinfelter’s)

18. PRIMARY LYMPHEDEMA CONTD.. It can be classified as – 1. Lymphedema Congenital 2. Lymphedema Praecox 3. Lymphedema Tarda

19. LYMPHEDEMA CONGENITAL Accounts for about 10% of cases Present at birth to less than 2 yrs of age Familial type is called as Nonne Milroy’s disease Type 1 familial AD disorder related to chromosome 5 1:6000 of live births B/L upper and lower limbs, genitalia and face may be involved.

20. LYMPHEDEMA PRAECOX Usually present at puberty Familial type is called as Letessier Meige’s Syndrome Type II familial AD Occurs between puberty and middle age

21. Lymphedema tarda presents in middle life after 35 yrs of age. Radiologically it can be classified as- 1. Hypoplasia (70%) 2. Aplasia (15%) 3. Hyperplasia (15%).

22. PATHOPHYSIOLOGY Decreased lymphatic contractility, valvular insufficiency and lymphatic obliteration Lymphatic hypertension and dilatation Accumulation of proteins, GF, glycosamines Increased collagen formation Deposition of proteins, fibroblasts- fibrosis Involves s/c tissue outside deep fascia v

23. SECONDARY LYPHEDEMA It can be due to- 1.Trauma 2.Surgery 3.Filariasis 4.TB/ Syphilis 5.Fungal infections 6.Advanced malignancy 7.Post radiotherapy 8.Rare causes like RA, Snake bites, DVT, CVI Sec. lymphedema develops rapidly

24. FILARIASIS Caused by W. bancrofti It was also called as Malabar leg. Shows nocturnal periodicity as it is related to night biting habits of the vector and sleeping habits of the host. Human being is the definitive host & female mosquito is the int. host Development or multiplication of microfilaria never occurs in human blood Life span of microfilaria in human blood is 3 mths and it is infective to female mosquito A density of approx 15 microfilariae/ drop of blood are needed to make it infective.

25. PATHOLOGY Recurrent lymphangitis Dermal lymphatics backflow Retrograde obliteration Recurrent Cellulitis Accumulation of protein, GF, Glycosaminoglycans

26. PATHOLOGY… Activation of Collagen & keratinocytes Protein rich lymphedematous tissue formation Sub dermal fibrosis Dermal thickening and dermal proliferation Cracks- ulceration abscess formation

27. EFFECTS OF W. bancrofti INFECTION Carrier stage Immune and allergic reactions Filarial fever, urticaria, pruritus, epididymoorchitis as acute presentations Occult filariasis Lymphadenitis & lymphangitis Lymphorrhagia, lymph scrotum, lymphocele, chyluria, chylous diarrhea, RP lymphangitis, chylous ascites, chylothorax Disease in the limb is confined to skin and s/c tissue as only superficial lymphatics are involved.

28. SITES OF LYMPHEDEMA Lower limbs- M/C Upper limbs Scrotum and penis [Ram’s Horn Penis] Breast Labia and eyelids

29. CLINICAL FEATURES Foot swelling extending progressively in the leg- Tree Trunk Pattern Buffalo hump on dorsum of foot Squaring of toes +ve Stemmer’s sign Edema- initially pitting Pain of varying intensity Debility/ immobility Eczema, fissuring, papillae formation, ulceration, lymphorrhea, elephantiasis Recurrent lymphangitis, cellulitis, abscess formation Pathological and social discomfort causing severe morbidity

30. BURNER’S GRADING Grade I- pitting edema which more or less disappears on elevation Grade II- non pitting edema which does not reduce on limb elevation Grade III- non pitting edema with skin changes Lymphedema can again be classified as- 1. Mild- < 20% of excess limb value 2. Moderate- 20-40% 3. Severe- > 40%

31. COMPLICATIONS Skin thickening, abscess and maggot’s formation Recurrent cellulitis, non healing ulcers, septicemia Recurrent Streptococcal infection Lymphangiosarcoma [Stewart Treves syndrome]- biopsy to confirm- chemo or radiotherapy, later even amputation may be required. Usually seen after mastectomy