Lymphorrhea is a condition in which lymph flows out onto the surface of the body or into its cavity. It develops with wounds of large lymphatic ducts, operations in areas rich in lymphatic vessels, spontaneous rupture of altered vessels against the background of a number of diseases. With external damage, a transparent, then cloudy liquid is released. With the internal outflow of lymph, an inflammatory process occurs. Lymphorrhea is diagnosed taking into account anamnesis, examination data, radiography, lymphography, pleural puncture, laparocentesis and other studies. Treatment – tamponade or ligation of the vessel, infusion therapy.
ICD 10
I89.9 Non-infectious disease of lymphatic vessels and lymph nodes, unspecified
Meaning
Lymphorrhea or lymphorrhagia is a rather rare pathological condition. It may have a traumatic or non-traumatic nature. The traumatic form of lymphorrhea is more often diagnosed in young and middle-aged people. Non-traumatic variant of pathology is detected mainly in patients of middle and older age groups. Minor loss of lymph does not pose a danger to the body. With massive single lymphorrhagia or chronic expiration, exhaustion develops, a fatal outcome is possible.
Causes
Lymphorrhagia is a polyethological condition that occurs during injuries, operations, and certain diseases. The main causes of pathology are considered to be:
- open and closed injuries of lymphatic vessels of considerable diameter, more often – the thoracic duct;
- accidental injury of vessels or manipulations on such vessels during operations in some anatomical areas;
- rupture of altered vessels in lymphangiectasia, vascular tumors, blockage by cancer emboli, especially against the background of lymphostasis and lymphangitis.
Changes in the chyletic vessels with an increase in the likelihood of their rupture and the development of lymphorrhea can be observed both in the extremities and in the wall of internal organs, for example, the intestine or bladder. Chronic circulatory insufficiency leads to the formation of a common lymphedema, in which lymph stagnation and vascular damage occur in all organs and systems.
Pathogenesis
The lymphatic system complements the circulatory system, participates in metabolic processes, provides drainage function, removing water and various compounds from the tissues. If the integrity of the lymphatic vessel is violated, the body loses fluid, proteins, fats and minerals, which leads to dehydration, metabolic imbalance and exhaustion.
Classification
Along with the outflow of chyletic fluid, the following variants of lymphorrhea are isolated:
- lymphocele – lymph accumulates in the tissues;
- chylothorax – fluid is detected in the pleural cavity;
- chylopericardium – lymph flows into the pericardial cavity;
- chyloperitoneum is a fluid found in the abdominal cavity.
The excretion of lymph in the urine due to its discharge into the urinary tract is called hiluria, leakage through the intestinal wall leads to the development of exudative enteropathy.
Symptoms
In the presence of a fresh open lesion with a violation of the integrity of the vessel, droplets are released or a trickle of transparent liquid flows out. With simultaneous injury of blood vessels, the color of the discharge varies from slightly pinkish to almost red. In the absence of medical care, the wound becomes infected after a few days, as a result of which the chyletic fluid becomes cloudy.
The formation of the chylopericardium is accompanied by swelling of the cervical veins, expansion of the boundaries of the heart during percussion, weakening of heart tones during auscultation, the occurrence or intensification of manifestations of heart failure. With a large amount of fluid in the pericardial cavity, hypotension, shortness of breath, and increased venous pressure are possible.
Minor chylothorax is asymptomatic. With a significant volume of pleural effusion, respiratory failure is noted, manifested by shortness of breath and cyanosis. Accumulation of less than 1 liter of lymph in the abdominal cavity is not visually determined. With a chyloperitoneum of a larger volume, the abdomen increases, in the standing position it hangs down, in the lying position it spreads out to the sides. In the lateral sections, a dulling of the percussion sound is detected.
Hiluria is manifested by staining urine in a milky white color. With exudative enteropathy, steatorrhea and chronic diarrhea are observed. With prolonged release of lymph into the intestine, the symptoms of malabsorption are determined. If lymphorrhea in the natural cavities and the lumen of hollow organs develops in heart failure, peripheral edema is detected in patients.
Complications
Significant loss of lymphocytes in lymphorrhea can cause secondary immunodeficiency. Due to the ingress of bacteria in external wounds, an infectious inflammatory process develops. When lymph accumulates in natural cavities (pleural, abdominal, pericardial), the work of internal organs is disrupted, aseptic chyletic inflammation occurs. Massive single or persistent chronic lymph loss leads to cachexia.
Diagnostics
Depending on the cause of the development of lymphorrhea, thoracic surgeons, oncologists, cardiologists and other specialists can diagnose this pathology. The diagnosis of external lymphorrhagia is made on the basis of anamnesis, complaints and the results of a physical examination. In case of internal lymph loss, additional studies are needed. Taking into account the localization of lymphorrhea, the following procedures can be prescribed:
- Radiography. With a chylothorax, a horizontal fluid level is detected in the lower parts of the chest, the darkening is homogeneous. With chyloperitoneum, high standing and limited mobility of the diaphragm are observed.
- Ultrasound. Echocardiography allows you to confirm the presence of fluid in the pericardial cavity and approximately determine its amount. Ultrasound of the pleural cavity provides information about the presence and volume of the chylothorax.
- Puncture of cavities. Required to clarify the nature of the liquid. The chylothorax is confirmed by pleural puncture. With a chylopericardium, a puncture of the cardiac sac is performed, with a chyloperitoneum, laparocentesis is performed.
- Laboratory tests. Traces of lymph are found in the urine (hiluria) or feces (exudative enteropathy).
- Lymphography. Radiopaque examination makes it possible to assess the state of the lymphatic system, identify blocks, determine the level of damage to the vessel.
Diagnosis of external lymphorrhea is usually not difficult. Lymphorrhagia in the body cavity must be differentiated from the accumulation of other fluids. Chylothorax is distinguished from hydrothorax, pleurisy, hemothorax. The chyloperitoneum is differentiated from various variants of ascites, the chylopericardium is differentiated from hemopericardium and exudative pericarditis.
Treatment
The patient is hospitalized in a hospital according to the profile of the underlying disease. Treatment tactics are determined by the localization of lymphorrhagia. The following techniques are used:
External peripheral lymphorrhea. With a slight release of chyletic fluid, a pressure bandage is applied, with insufficient effectiveness of this method of treatment, tamponade is performed. Stitching or coagulation of the vessel is rarely required.
- Chylothorax. Pleural punctures are performed, in the absence of a result, a ligation of the thoracic duct is required using a thoracotomy or thoracoscopy.
- Chyloperitoneum. Lymph aspiration is performed by laparocentesis. Ineffectiveness of treatment is an indication for laparotomy or laparoscopic surgery.
- Chylopericardium. Pericardial punctures are performed. With a persistent course, thoracoscopy or thoracotomy is necessary to ligate the lymphatic vessel.
The treatment plan for exudative enteropathy and hiluria is determined taking into account the nature and prevalence of vascular pathology. Conservative treatment of all types of lymphorrhea involves infusion therapy to compensate for the lack of fluid, nutrients and trace elements. In case of recurrent lymphorrhea due to blocking of lymph outflow, reconstructive interventions are performed.
Forecast
With minor injuries and rapid stop of lymphorrhea in the case of acute conditions, the prognosis is favorable. Lymphorrhagia, which has developed against the background of chronic pathologies of the lymphatic system, is more difficult to treat, especially in the case of common vascular lesions. With persistent massive lymphorrhea, the prognosis is serious, the patient may die due to exhaustion and metabolic disorders.
Prevention
Prevention of surgical injuries involves compliance with the technique of interventions, aspiration drainage of the wound or the imposition of a pressure bandage after removal of regional lymph nodes during oncological operations. It is necessary to timely identify and treat conditions that can lead to the development of lymphorrhea.
