Abdominal Lymphatic System Research Articles

Intestinal tuberculosis mimicking Crohn‘s disease: clinical case

Ieva Stainytė1, Martyna Vyčaitė1, Irma Kuliavienė2 1Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania 2Hospital of the Lithuanian University of Health Sciences Kauno klinikos, Department of Gastroenterology, Kaunas, Lithuania Abstract Background. Gastrointestinal (GI) tuberculosis (TB) is a relatively rare form of tuberculosis that can affect the peritoneum, abdominal organs or the abdominal lymphatic system. As an extrapulmonary form, intestinal tuberculosis accounts for 2% of cases of this disease worldwide. Intestinal damage caused by Mycobacterium tuberculosis (M. tuberculosis) presents with nonspecific complaints such as constitutional symptoms, abdominal pain and changes in bowel movements. The most common site of damage is the ileocecal valve. People with immunosuppressive conditions are at greater risk of developing this disease. Clinical case. This article presents a clinical case of a patient in whom the initial diagnosis of Crohn’s disease (CD) and treatment with glucocorticoids were incorrect. Persistent symptoms led to consideration of ineffective treatment and alternative diagnoses, therefore, it was decided to perform a repeated fibrocolonoscopy (FCS). Ultimately, only a positive culture for M. tuberculosis confirmed the diagnosis of intestinal tuberculosis. Conclusions. This clinical case reflects the complicated diagnosis of intestinal tuberculosis and its differentiation from Crohn’s disease, which is determined by non-specific symptoms and insufficiently sensitive standard tests. A detailed examination, including fibrocolonoscopy with multiple biopsies for histological examination and microbiological identification of M. tuberculosis, is important for establishing the diagnosis. Multiplex polymerase chain reaction (PCR) testing is recommended when possible. Keywords: gastrointestinal tuberculosis, intestinal tuberculosis, M. tuberculosis. Full article https://doi.org/10.53453/ms.2023.2.16

Chylous ascites as a marker for intestinal viability in a small bowel obstruction: a case report.

Chylous ascites (CA) is the uncommon extravasation of triglyceride-rich fluid into the abdominal cavity as a result of the disruption of the abdominal lymphatic system. A patient who had previously undergone a subtotal colectomy presented with a closed-loop small bowel obstruction (SBO), underwent an emergency laparotomy with adhesiolysis and had intra-operative findings of milky intra-abdominal free fluid confirmed on analysis as CA. His post-operative period was complicated by a prolonged ileus, and following resolution, he was subsequently discharged home. Here, we present a case of a closed-loop SBO in which CA may be an indicator of intestinal viability.

Biological Effects of Abdominal Irradiation on Intestinal Barrier Breakdown Identified By Second-Generation Probiotic, LR-IL-22

Toxic effects of total body irradiation and whole abdomen irradiation include breakdown of the intestinal barrier function and bacterial translocation into the abdominal lymphatic and systemic vascular circulations. Therapeutic effects of countermeasures against intestinal radiation damage have relied upon serum assays for bacterial endotoxin and citrulline, biomarkers of relatively late effects in barrier dysfunction. Intestinal barrier breakdown effects on mesenteric lymph nodes and spleen have been incompletely documented. In the present experiments, we gavaged C57BL/6NTac female mice one hour before irradiation (19.75 Gy whole abdomen) with 100 microliters containing 109 second-generation probiotic, Lactobacillus reuteri-Interleukin-22 (LR-IL-22) containing transgenes for both mammalian IL-22 and Rapamycin resistance (Alexander LM, et. al., Applied and Environmental Microbiology 85(10): e02335-18, 2019), LR alone, or sham-gavage. Twenty-four hours later, Peyer's patches, mesenteric lymph nodes, spleen, and peripheral blood were collected at serial times after gavage and assayed for growth of Rapamycin-resistant bacteria, and for relative compositions of immunocytes in mesenteric lymph nodes spleen and blood including: CD3, CD19, CD8, CD45, NK1.1, CD25, Foxp3, CD103, and PD-1+ lymphocytes. Compared to non-irradiated, non-gavaged mice, animals receiving LR or LR-IL-22 showed no significant changes in weight or length of the spleen or lymph nodes 24 hr after gavage. There was an increase in PD-1 expression in the spleen of the mice gavaged with LR-IL-22. There were no other significant changes in the composition of immunocytes in abdominal lymph nodes, or spleen and detectable second-generation probiotic growth in these organs. At 24 hr after irradiation, abdominal irradiated mice demonstrated a significant loss of weight and length of the spleen (p < 0.05) as well as decreased lymphocytes in the blood (p < 0.05). Mice gavaged with LR-IL-22 and irradiated to 19.75 Gy had a significant increase in lymphocytes and red blood cells compared to irradiation only (p < 0.05). There was no significant change in the size or weight of the lymph nodes. In the lymph nodes there was an increase in CD8+ cells after irradiation while the LR-IL-22 gavaged mice had an increase in PD-1 expression. There was no detectable growth of Rapamycin resistant bacteria in non-gavaged animals. Mice gavaged with LR-IL-22, but not LR showed decreased biomarkers of intestinal barrier breakdown. Thus, gavage of genetically labeled second-generation probiotics represents a sensitive assay system for irradiation changes in the intestinal barrier function, translocation of bacteria into the abdominal lymphatic system, and therapeutic effect of enteric delivered radiation countermeasures. Supported by U19-AI1068021 Grant. Disclosures No relevant conflicts of interest to declare.

Abdominal lymphatic system visibility, morphology, and abnormalities in children as seen on routine MCRP and its association with immune-mediated diseases.

(1) To assess the visibility and diameters of the thoracic duct (TD) and cisterna chyli (CC) on MR cholangiopancreatography (MRCP) in children. (2) To evaluate for the presence of any lymphatic abnormalities and assess their association with diseases in which the immune system is implicated in etiopathogenesis. This retrospective study included 142 MRCPs performed in children 8-17years old and without prior surgeries. Two radiologists reviewed all exams for visibility and diameters of the TD and CC, and presence of abnormal lymphatic collaterals. TD and CC diameters in various disease processes were compared using Student's t tests. The association of collaterals with immune-mediated diseases was assessed using Fisher's exact tests. The TD and CC were seen in 134/142 (93.7%) cases with mean diameter of 3.25 ± 1.07mm and 126/142 (88.7%) cases with mean diameter of 4.55 ± 1.37mm respectively. The mean diameter of CC was larger in patients with portal hypertension (p = 0.021). There were no significant differences in the TD and CC diameters between immune-mediated and non-immune-mediated diseases. Retroperitoneal collaterals were seen in 41/142 (28.8%) of cases and were associated with both portal hypertension (p = 0.0019) and immune-mediated diseases (p = 0.0083). The TD and CC can be visualized in the majority of children on routine MRCP images, and CC has larger diameter in patients with portal hypertension. The association of collaterals with immune-mediated diseases supports a potential role of the lymphatic system in the etiopathogenesis of immune-mediated diseases. • The lymphatic system has been increasingly implicated in a number of inflammatory and immune-mediated diseases. • The abdominal lymphatic system can be visualized in the majority of children above 8years on routine MRCP images. Similar to adult studies, the cisterna chyli is significantly larger in children with portal hypertension. • Retroperitoneal lymphatic collaterals, seen in 29% children, are associated with immune-mediated diseases, which supports the potential role of the lymphatic system in the pathogenesis of immune-mediated diseases.

Development of a mouse model for the visual and quantitative assessment of lymphatic trafficking and function by in vivo imaging

Methods for quantitative analysis of long distance lymphatic transport of nanoparticles in live animals are yet to be established. We established a mouse model for analysis of time-dependent transport just beneath the abdominal skin to investigate lymph node-to-lymph node trafficking by in vivo imaging. For this purpose, popliteal lymph nodes (PLNs) as well as efferent and afferent lymphatic vessels, marginal veins, and feeding blood vessels were surgically resected to change the lymphatic flow from footpad injections. Using this model, we observed a novel lymphatic flow from the footpad to the proper axillary lymph node (ALN) via the inguinal lymph node (ILN). This drainage pathway was maintained over 12 weeks. Time-dependent transportation of 1,1′-dioctadecyltetramethyl indotricarbocyanine iodide-labelled liposomes from the footpad to the ILN was successfully quantified by an in vivo imaging system. Moreover, congestion and development of a new collateral lymphatic route was visualised under a lymphedema status. Histological analysis of abdominal skin tissues of this model revealed that PLN resection had no effect on the abdominal lymphatic system between the ILN and ALN. These data indicate that this model might be useful to clarify the mechanisms of lymphedema and study direct transportation of lymph or other substances between lymph nodes.

Imaging of abdominal tuberculosis.

The concept of "abdominal tuberculosis" in this review refers to peritoneum and its reflections, gastrointestinal tract, abdominal lymphatic system, and solid visceral organs, as they are subject to varying degrees of involvement alone or in combination. Some features, including free or loculated ascites with thin-mobile septa, smooth peritoneal thickening and enhancement, misty mesentery with large lymph nodes, smudged omental involvement, and advanced ileocecal changes demonstrated by US, CT, or gastrointestinal series are deemed suggestive radiological findings. The diagnosis still requires a high index of suspicion, once the suggestive features have been demonstrated by imaging modalities.

Neoadjuvant Concurrent Chemoradiotherapy Followed by Definitive High-Dose Radiotherapy or Surgery for Operable Thoracic Esophageal Carcinoma

Purpose: A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. Materials and Methods: Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80–100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500–1000 mg/body/day, mean: 400 mg/m2, Days 1–4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60–70 Gy for Tis, T1 and 65–75 Gy for T2–T4 tumor with high-dose–rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. Results: At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the ’esophagus conservation’ was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). Conclusion: Our results demonstrated that almost all early disease (Stage 0–I) and about half of advanced disease (Stage II–III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy.

Blood in the lymph (hemochylia) and intestinal lymphangiectasia associated with Lutembacher's syndrome

A 31 year old man presenting with Lutembacher's syndrome and protein-losing enteropathy is described. Reversal of the protein-losing enteropathy 7 months after cardiac surgery suggested that it was secondary to the cardiac disorder. Spontaneous rupture of a congenital aneurysm of the splenic artery created a spleno-portal arteriovenous fistula which caused a massive sequestration of blood into the dilated abdominal lymphatic system, severe hypovolemic shock and death. The pathogenesis and relation of two rare disorders of the lymphatic system, contamination of the lymph with blood (hemochylia) and intestinal lymphangiectasia are discussed.

Protein-losing gastroenteropathy and cardiac diseases

1) Nine cases (21 per cent) of 43 cases of constrictive perecarditis showed severe hypoproteinemia under 5.0 Gm. per 100 ml., while only one case with such hypoproteinemia was encountered among congestive failure of the other cardiac diseases with high venous pressure over 150mm. saline. This special case was a postoperative teralogy of Fallot accidentally associated with tricuspid and pulmonary insufficiency. 2) Isotope studies on cases with hypoproteinemia under 5.0 Gm. per 100ml. of serum protein (5 cases of idiopathic hypoproteinemia and 3 cases of cardiac diseases) showed definite evidence of protein loss into the gastrointestinal tract. 3) Comparing the venous pressure and duration of signs of venous congestion, among group with hypoproteinemia under 5.0 Gm. per 100 ml., the other group of constrictive pericarditis, and cases with congestive failure associated with tricuspid insufficiency, the important role of hemodynamic abnormalities on severe hypoproteinemia was confirmed. At the same time, it was pointed out that venous congestion is not a sufficient factor but one of necessary factors to explain the hypoproteinemia in individual cases. 4) Preliminary experimental study designed to clarify causal relationship of venous congestion to abnormality of abdominal lymphatic system and protein loss into the gut was reported. 5) A case of constrictive pericarditis whose clinical findings showed some special features inherent to those of idiopathic hypoproteinemia due to protein losing enteropathy, was described, and some clnical statistics concerning some possible factors other than hemodynamic abnormalities were presented.

Chylous ascites: Report of a case with recovery and survival after fourteen years

Summary A case of chylous ascites is presented in a Negro infant whose abdominal enlargement was first observed by the parent at the age of 2 months. Therapy consisted of periodic abdominal paracentesis for removal of fluid, Olac formula, parenteral fluids, and oral vitamins. The chylous ascites gradually but completely disappeared clinically by the end of the first year of life. Approximately fourteen years after treatment the child is normal and shows no evidence whatsoever of the old infantile complaint. The exact mechanism of the condition in this case was not determined but represented a probable congenital anomaly or birth injury involving the abdominal lymphatic system. General aspects of etiology and therapy are discussed.