LYMPHOEDEMA AND ELEPHANTIASIS

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LYMPHOEDEMA AND ELEPHANTIASIS

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Thursday, 10 December 2009 20:24

LYMPHOEDEMA AND ELEPHANTIASIS
What is elephantiasis?
It is a hypertrophic condition of skin and S.C. tissue which make the skin & subcutaneous tissue like those of an elephant. Due to the fact that elephantiasis is usually due to Ch. Lymphatic obstruction "Lymphoedema", both names are used instead of the other.
What are other Causes of elephantiasis?
It may, rarely, occur due to:
1- Postphlebitic leg.
2- Congenital A.V. Fistula.
3- Elephantiasis neuromatosa.
4- Leprosy.
Causes of Lymphoedema:
I- Congenital: "Mallory's oedema"
It is of 3 subtypes:
1- Lymphoedema congenita: Marked hypoplasia of lymphatics dated since birth.
2- Lymphoedema precox: Appears at puberty.
3- Lymphoedema tarda: Minimal lymphatic deficiency appears later on.
II- Traumatic: "Rare type"
Due to either  Crush injury obstructing lymphatic
 Circumfrential trauma : rare.
III- Inflammatory: obstruction  inflammation  obstruction.
A- Filarial obstruction:
ط The commonest cause in tropics.
ط The adult worms obstruct the lymphatics.
ط Obstruction  2ry strept. Infection  lymphangitis  fibrosis  further obstruction.
ط The adult worm of Wachereria bancrofti send microfilariae to circulation at night So, diagnosed by nocturnal sample.
B- Infective Lymphoedema:
1- Specific e.g. TB & erysipelas.
2- Non specific: recurrent attacks of staph. & strept infections.
this type tend to be localized e.g. eye lid and scrotum after recurrent erysipelas.
IV- Neoplastic
Due to invasion of all lymphatic drainage of an organ by malignancy "rare "
V- Idiopathic:
After recent investigations many cases of this type can be attributed to one of the previous causes.
Pathology:
1- Obstruction of the lymphatics by any cause  early pitting oedema.
2- Retention of the lymph which is protein rich fluid.  Infiltrating the tissues.
3- This protein rich fluid stimulate proliferation of fibrous tissue  thickening and oedema of the skin and S.C. tissues. which is non pitting.
4- The stasis may precipitate recurrent attacks of lymphangitis which may cause more obstruction.
5- The sites of affection in order of frequency:
a- The Lower Limb.
b- Ext. genitalia esp. scrotum.
c- Rarely the upper limb & breast.
Cl. Picture:
Early  Pitting oedema which subside by limb elevation.
Late  Thickening of skin & S.C tissues  non pitting oedema. The oedema is absent at:
a- around the ankle joint  deep furrow.

b- In the sole of the foot. why? because these sites are devoid of S.C. tissues.
 In rare cases the distended lymphatics may cause vesicles on the affected part which may rupture  ulceration.
 In septic elephantiasis fever is present "elephantoid fever".
Investigation: Lymphography
 Visual method: By injection of patent blue dye in the web spaces of the foot to delineate the lymphatic vessels of the lower limb.
 Radiological method: Done after injection of the dye (Ultra lipid) into the lymphatic vessesl seen by visual method.
Treatment
I- Early Cases:
q Medical treatment
ط Elevation of the limb.
ط Elastic bandage.
ط Antibiotics for 2ry infection.
ط Hetrazan only prevent spread of Disease in the community.
q Surgical:
Lymphangioplasty for creation of new channels to drain lymph. e.g. omental transposition & L.V. shunts.
II- Late Cases:

(1) Kondoleon 's operation:
Excision of wide strip of deep fascia to drain sup. lymphatics to deep lymphatics.it may prevent progress but does not reduce the size.
(2) Sistrunk 's operation:
Excision of a bulk of tissues from the inner & outer sides of the leg.
Cystic Solid
Haematoma
Erysipelas
cellulitis
Abscess
Furuncle
Carbuncle
Ch. abscess
Cold abscess
Sebaceous cyst.
Dermoidm cyst.
Simple ganglio
Bursitis
Haemangioma
Lymphangioma.
I- Inflammatory:
T.B. of the skin
Condylomata lata
Condylomat acuminata
II- Tumour like conditions:
Callosity
Corn
Keloid
Wart
III- Tumours:

1- Tumours of epithelium
Benign:
• Papilloma
• Keratoacathoma
• Benign calcifying epithelioma
• Pyogenic granuloma
Malignant
• Sq. cell carcinoma
• Basal cell carcinoma
2- Tumours of pigment cell origin
Benign: Melanoma
Malignant: Melanoma
3- Tumours of subepidermal origin
Benign: Dermato fibroma
Malignant: Dermato fibrosarcoma
4- Tumours of nerve origin
Benign: Neurofibroma
Malignant: Neurofibroma
5- Connective tissue Tumours
Benign
• Lipoma
• Fibroma
• Leio or Rhabdomyoma
Malignant
• Liposarcoma
• Fibrosarcoma
• Myosarcoma
6- Mixed Tumours
Teratomas & Hamartomas
• Reduce the size but recurrence is common.
(3) Charle 's operation:
Excision of all hypertrophied subcutaneous tissues up to the muscles then application of epidermal graft from the excised tissues on the muscle.
• Good results but cosmetically bad.
(4) Thompson swiss roll operation:
The method is to bury the dermal part of the excess skin like a swiss-roll cake along the whole length of the leg , so that the subdermal lymphatic may assist drainage.
(5) Plastic reduction: in cases of scrotum vulva and breast lymphoedema.
(6) Amputation: May be needed in grossly damaged limbs making the patient disabled by its weight.
SOURCE: Prof. AYMAN SALEM'S BOOK
Copyright: (Vascular Society of Egypt ) & (Medical Educational web)
Not to be reproduced without permission of Vascular Society of Egypt

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