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Lymphography

By
Dr/ Dina Metwaly

lymphatic system
it is part of thecirculatory system, comprising a
network oflymphatic vesselsthat carry a clear
fluid

called

lymphdirectionally

towards

the

heart.

The lymphatic system consists of lymphatic


organs, a conducting network of lymphatic
vessels, and the circulatinglymph
.
circulating

The Lymphatic System functions

Transport clean fluids back to the


blood

Drains excess fluids from tissues

Removes debris from cells of


body

Transports

fats

from

digestive

system

Slide 12.1

Lymphatic System

Thymus
Gland
Lymph
Vessels
Lymph Nodes
Spleen
Tonsils

Lymphatic Capillaries

Fluid leaks through mini-valves into lymph capillaries

Higher pressure on the inside closes mini-valves

Lymphatic Vessels

Collects lymph from lymph


capillaries

Delivers lymph to lymph nodes

Returns

fluid

to

circulatory

veins near the heart

Right lymphatic duct

Thoracic duct

Lymphatic System Structures

Lymph Nodes
Filter lymph before it is returned
to the blood
Defense cells in nodes:
Medulla houses macrophages
which

engulf

and

destroy

foreign substances
Cortex nurtures lymphocytes
which

provide

immune

response to antigens (cortex)

Lymphoid Organs

Several

other

organs

contribute to lymphatic
function
1.

Spleen

2.

Thymus

3.

Tonsils

4.

Peyers patches
Figure 12.5

The Spleen

Filters blood

Destroys worn out blood cells

Forms blood cells in the fetus

Acts as a blood reservoir

The Thymus

Functions at peak levels only


during childhood

Produces

hormones

thymosin)
lymphocytes

to

(like

program

Tonsils

Small masses of lymphoid


tissue around the pharynx

Trap and remove bacteria and


other foreign materials

Tonsillitis

is

caused

congestion with bacteria

by

Peyers Patches Tonsils of the intestine

Found in the wall of the small intestine

Capture and destroy bacteria in the


intestine

Lymphography
General

term

applied

to

the

radiologic examination of:


Lymph

nodes

(lymphadenography):
radiographic visualization of the
lymph nodes .

Lymph

Vessels:

endovascular

injection of radiopaque material


into a lymphatic vessel

Usually done to demonstrate pelvis and


abdomen
Injected in foot

For axillary, clavicular area and upper limbs


Injected in hand Checks drainage of lymph
nodes

Indications

Edema

in

Visualization

limbs
of

by
vessel

obstruction

Infections

Rule out cancer

Lymphoma staging & Check


for metastasis

Size,

shape,

enlarged nodes

location

of

Contraindications

Pregnancy

People with allergies to iodine-based


contrast dyes.

people with severe chronic lung, heart,


kidney, or liver disease.

Pre Procedure

Obtain PT history

Obtain PT consent

Make sure to have all supplies

Make sure the absence of contraindications,


which are cardiovascular or pulmonary
disease

Positioning aides and comfort supplies

Contrast

Water based (less commonly used as it diffuse in


nearby tissues).

Oil based

More commonly used

Ethiodal

Lipodal

Dose: The total amount of oily contrast medium


injected on each side should never exceed 10 mL

Procedure of lower limb


lymphography (pedal
lymphangiography)

Injection of mixture of local anesthesia + methylene


blue violet on the dorsal aspect of the foot between the
toes.

longitudinal incision ---> isolation of lymphatic vessel


from the surrounding fatty tissue

visualization

of

superficial

collectors

after

subcutaneous injection of contrast material


1.

into the first and second inter-metatarsal spaces


of the dorsal foot (for superficial circulation)
or

2.

or lateral retro-malleolar space (for deep


circulation)

Nodes in pelvis and abdomen are demonstrated


with foot injection

A needle orcatheteris inserted into a lymphatic


channel in either the foot or arm, and a contrast
medium is injected into the body at a very slow rate
(approximately 60 to 90 minutes for all the contrast
medium to be injected).

Afluoroscopeis used to follow the dye as it spreads


through the lymphatic system through the legs, into the
groin, and along the back of the abdominal cavity.

Once the contrast medium is injected, the catheter is


removed, and the incisions are stitched and bandaged.

Filming

X-rays are usually taken 1 HR after pressure


injection that takes about 45 minutes

After 1 hour

24 hrs

48 hrs (if needed)

72hrs (if needed)

First hour= Contrast in lymph ducts

24 hours = If lymph nodes

After 1 hour=
Lymphangiograms

the first films are taken


usually

of

the

lymph

vessels the upper body or


any area of interest.

These first flims are called


Lymphangiograms!

Lymphadenograms

24 hours after the


Lymphangiograms
are taken the patient
has to come back to
have the films taken
of the lymph nodes
called
lymphadenograms!

upper limb
lymphography

injection of contrast agent in a collector of


dorsal radio-carpal surface (for superficial
circulation) or ulnar retro-styloid location
(for deep circulation)

radiography of the lymphatic channels from


forearm to axillary lymph nodes

Upper Limb
Lymphography

Normal appearances and


variations
1.
a)

b)

Normal appearance of lymph nodes.


Lymphogram (filling phase): shows
appearance of the lymph nodes.

homogeneous

Lymphogram (nodal phase): shows a smooth peripheral


indentation (arrowheads), which corresponds to the hilar
area.

a) filling

b) Nodal

Para-aortic nodes have proved to


be the most reliable group for
showing

features

of

high

diagnostic accuracy

The cisterna chyli is usually a


saccular structure less than 5 cm
in length usually lies at the
midline of the body of L1 but may
also be situated on either side of
the midline.

Lymphogram shows normal


cisterna chyli and the abdominal
segment of the thoracic duct.

The thoracic duct sharply merges into the junction of


the left subclavian vein and left internal jugular vein

Some rarely seen nodes are situated extrinsically to


the usual lymphographic regions, such as the
popliteal, posterior intercostal, mediastinal, bilateral
hilar, paratracheal, and supraclavicular nodes

Figure:
Lymphogram
shows
Normal
appearance of the thoracic duct. the termination
of the thoracic duct at the left subclavianjugular venous anastomosis at the base of the
neck

Iliopelvic-aortic Lymphatic
System

Iliopelvic Abdominoaortic
Lymph Nodes

Inguinal Region

Lymphography

Lipiodol lymphography: Left image: After the injection of contrast material


(lymphangiographic phase) the normal lymphatic vessels of the minor pelvis
are visualized. Right image: 24 hours after the injection normal inguinal,
pelvic and paralumbar lymph nodes are demonstrated (nodal phase).

complications

The major complications of lymphography are


caused by the vital dye and contrast materials
rather than the technique

Major frequent complication:


pulmonary oil embolization
Pulmonary infarction

1.
2.

3.

1.
2.
3.

hypersensitivity to methylene blue dye and


ethiodized oil
Rare complication:
intraalveolar hemorrhage
hypothyroidism
systemic arterial embolization to the brain or
kidney

Post Procedure
1.

Watch for signs of infection

Swelling red and warm to touch

Accompanied by a fever

Contact DR right away

2.

Drink lots of water

3.

Major swelling in one limb

Especially limb injected

Conclusion

This procedure has largely been replaced by noninvasive MRI or CT procedures.

However, lymphography has the unique capability


of

demonstrating

internal

architectural

derangements within normal-sized lymph nodes.


This

highly

valuable

advantage

makes

lymphography diagnostically more accurate than CT


(which demonstrates size rather than architecture)

Lymphography

still

has

cornerstone

role

in

Q & A?

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