LYMPHEDEMA

6.2 LYMPHEDEMA

ETIOLOGY

Is usually due to obstruction or destruction of normal  lymphatic

channels.

Congenital  lymphedema  is  due to  hypoplasia  or  aplasia  (non

development)  of lymphatics. Obstruction of lymphatics  may  also

occur   because  of  tumours,  repeated  infection  or   prasitic

infestation. The number of lymphatic channel and lymph glands  is

in adequate for draining lymphatic fluid.

Excision  of  lymphatic nodes as during  radical  mastectomy  and

radical groin dissection and radiation therapy may also result im

lymphedema

This edema increases during the day and decreased overnight.

The main complaints are fatigue, and cosmetic defect

Elephantiasis   (thickened   skin)is  a  complication   seen   in

filariasis (Discussed in chapter)

PHYSICAL FINDINGS

*  In early stages the lymphedema, pitting is possible

*  The lymphedema is firm rubbery and non-pitting at later stage.

   There may be small blisters in the skin.

DIFFERENTIAL DIAGNOSIS

Unilateral  lymphedema  needs  to be  differentiated  from  soft,

pitting, bilateral edema seen in heart failure and renal failure

Treatment

Conservative measures include elevation of the limbs and  control

of infection.

Surgical Treatment

Silk threads; strips of fascia and pedicle grafts have been tried

to provide alternative passage for fluid

Alternatively  excision of all the skin and  subcutaneous  tissue

followed  by  application of split-thickness  has  also  relieved

symptom of heavy limb.

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LYMHATCS LYMPHANGITIS

 LYMPHATICS

ANATOMY

The  intestitial spaces (space between cells) have a fluid.  This

fluid  for  its retrun to circulation has a system of  very  fine

tubes  the  lymphatics.  They  are lined by  a  single  layer  of

endothelial  cells some lymphatics have contractile muscle  cells

in their walls

The  lymphatics drain into the regional lymph  glands  (Fig.23.3)

after  the  lymphatic fluid has been filtered through  the  lymps

gland   another set of lymphatics that emerges from the  hium  of

the  gland  and  the prepheral lymph  finally  enters  the  veins

through the lymph in the thoracic ducts.

6.1 LYMPHANGITIS

Infection  of the skin and subcutanaeous tissue by  Streptococcai

pyogenes produces severe inflammation of the lymphatics resulting

in painful red streaks of lymphatics and enlarged draining  lymph

glands.  Sometime  the  draining lymph gland is the  site  of  an

abscess.

6.1.1 Treatment

It is with bed rest and antibiotics. Early incision and  drainage

of abscess is required.

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RUPTURED SPLEEN

RUPTURE OF THE SPLEEN

Rupture of the spleen may occur as a consequence of blunt  injury

of the abdomen or a gunshot wounds.

The  spleen, alone or in combination with other viscera,  is  the

most  frequently  injured  organ following  blunt  trauma to  the

abdomen or the lower thoracic cage. Automobile accidents  provide

the  predominating cause, while falls, and blows incurred  during

contact sports are frequently implicated in children.

Clinical manifestations.

The  signs  and  symptoms produced by trauma to the  spleen  vary

according  to  the  severity  and  rapidity  of   intra-abdominal

hemorrhage. The majority of patients present with some degree  of

hypovolemia and techycardia is almost always present.

The  patient  usually complains of  generalized  upper  abdominal

pain,  which is one third of the cases is localized in  the  left

upper quadrant. Pain at the tip of the shoulder (Kehr's sign)  is

evidence of diaphragmatic irritation but occurs in less than half

the  patients.  If  the patient is placed  in  the  Trendelenburg

position, left shoulder pain may be produced.

Diagnostic Studies

Routine  abdominal  radiographs may  demonstrate  fractured  ribs

which:

1. Elevated immobile left diaphragm

2. An enlarged splenic shadow

3. Medial displacement of the gastric shadow with

4  Widening  of the space between the  splenic  flexure  and  the   

   proportional   fat  pad.  Abdominal  paracentesis   yields   a   

   positive tap.

Treatment

The   great   majority  of  adult   patients   require   surgical

intervention.

Splenectomy  as a life saving procedure is still the  standard  in

many cases.

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Immune Idiopathic Thrombocytopaenic Purpura

IMMUNE (IDIOPATHIC) THROMBOCYTOPENIC PURPURA (ITP)

The syndrome is characterised by :

*  A reduced number of platelets in the peripheral blood

*  Abundance of megakaryocytes in the bone marrow

*  Shortened platelet life span and

*  An immunologic pathogenesis

*  Indirect  evidence is presence of an antiplatelet  factor  IgG

   antibody in the plasma

*  It can be demonstrated that platelets coated with the antibody

   are being selectively sequestered in the spleen

*  The major site of cell destruction can also be in the liver

The acute form is prominent in male children under the age of ten

with  a  history  of antecedent  viral  or  bacterial  infection. 

Idiopathic thrombocytopenic purpurra occurring in the absence  of

viral infection and in young adults has a female : male ratio  of

3:1.

Clinical manifestations include :

*  Petechiae

*  Eccymoses

*  Epistaxis

*  Bleeding gums

*  Vaginal bleeding

*  Gastrointestinal bleeding

*  Hematuria

Treatment splenectomy may be helpful in some cases.

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