It refers to the presence of free chyle in the peritoneal cavity, also called chyloperitoneum. It may have very different causes, therefore accurate clinical investigations are necessary in order to design a correct and adequate medical-surgical therapy. The most frequent causes are: neoplastic infiltration of visceral lymphatic-lymph node structures, trauma (often of iatrogenic nature, such as, for example, during extensive lymphadenectomies in surgical therapy of kidney cancer), or lymphangiodysplasia.

CHYLOUS ASCITIS

 

It is an ampulla-shaped dilation at the beginning of the thoracic duct; it may be up to one and a half centimeter in diameter, it is normally anterior to the initial lumbar vertebrae, posterior to the aorta, and medial to the right medial pillar of the diaphragm. In some cases, where the origin of the thoracic duct is particularly high – e.g. at the level of the last thoracic vertebrae –

 

Effusion of chyle in a joint cavity.

 

Discharge of chyle through the uterus or the vagina.

 

Discharge of chyle through urinary excretion pathways. Urine acquires a unique milky, and whitish appearance, due to chyle mixed with urine. In the majority of cases, it is due to fistulas that link the urinary excretion pathways – from the pelvis of the kidney – with the retroperitoneal lymphatic and chyliferous system. It can be caused by traumas – of iatrogenic origin (such as, for example, following extensive para-aortoiliac lymphadenectomies in urologic surgery) -, or it can be correlated with complex dysplasia of intestinal and retroperitoneal chyliferous and lymphatic vessels.

 

  • Stage 1
    • IA: No edema, but presence of lymphatic impairment (with lymphatic stasis detected by scintigraphy).
    • IB) Mild edema reversible with limb elevation and night rest.
  • Stage IIA: Persisting edema, with only partial regression with limb elevation and night rest.
  • Stage IIB: Persisting edema (no spontaneous regression with limb elevation) and progressing disease (acute erysipeloid lymphangitis).
  • Stage IIIA: Fibrolymphedema (initial lymphostatic verrucosis) with “column-shaped” limb.
  • Stage IIIB: Elephantiasis with severe deformation of the affected extremity, marked and extended, sclerodermic pachidermitis and lymphostatic verrucosis.

 CLINICAL STAGING OF LYMPHEDEMA  CLINICAL STAGING OF LYMPHEDEMA  CLINICAL STAGING OF LYMPHEDEMA  CLINICAL STAGING OF LYMPHEDEMA

 

II Stage lymphedema of the right lower limb.

post-mastectomy lymphedema post-mastectomy lymphedema post-mastectomy lymphedema

A) II Stage post-mastectomy lymphedema of the left upper limb. B) Lymphoscintigraphy: on the right, normal lymphatic drainage and healthy lymph nodes. C) Lymphoscintigraphy: on the left, absence of lymph nodes homolateral to the operated breast.

III Stage post-mastectomy lymphedema III Stage post-mastectomy lymphedema III Stage post-mastectomy lymphedema

A) III Stage post-mastectomy lymphedema of the right upper limb. B) Lymphoscintigraphy: on the right, significantly dilated and convoluted lymphatic collectors. C) Lymphoscintigraphy: on the left, healthy lymphatic pathways
 
III Stage lymphedema III Stage lymphedema III Stage lymphedema III Stage lymphedema
A) III Stage lymphedema of the right lower limb B) Lymphoscintigraphy. C) IV Stage Lymphedema of the lower limbs. D) At lymphoscintigraphy, a bilateral stasis is observed, with greater tracer uptake on the right.
 
V Stage lymphedema V Stage lymphedema V Stage lymphedema  V Stage lymphedema V Stage lymphedema V Stage lymphedema

V Stage lymphedema of the left lower limb with angiodysplasia and significant lymphostasis also in the external genitalia.

 

It is caused by a more or less serrated, in the majority of cases monolateral, stenosis of the iliac vein. It may be due to a congenital anatomic condition or it can be secondary to traumas also of iatrogenic nature. It is the cause of severe homolateral venous stasis and it is often accompanied by lymphatic insufficiency.

 

It is the most abundant protein in our body, accounting for almost 1/3 of all our body proteins. Collagen is organized into fibers which, in turn, consist of microfibrils. Practically present everywhere, it forms a support and a basic structure to connective tissues.

 

Today, it is the most commonly applied diagnostic tool for non-invasive anatomic investigations of vascular – venous as well as arterial – structures. It combines the ultrasonographic technique with the physical doppler principle, thus allowing for a good display of the vessels under examination, the identification of their actual anatomy, and the presence of any stenosis or atheromasic plaques. With this imaging technique, bloodstream amount, direction, and velocity can be accurately invesigated. An accurate study of vascular, especially venous, structures, with color-Doppler ultrasound is key for proper lymphatic edema assessment. Indeed, it is necessary to identify any concurrent venous insufficiency, since it could worsen the clinical picture, or the presence of arterial insufficiency, in which case a prolonged application of elastic bandaging should not be recommended.

COLOR-DOPPLER ULTRASOUND COLOR-DOPPLER ULTRASOUND COLOR-DOPPLER ULTRASOUND

During investigations of lymphedema affected extremities with Color-Doppler Ultrasonography, lymphatic spaces and dilated lymphatic collectors can be clearly identified, and arterial and venous circulation conditions accurately assessed.

 

 

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