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Tamir S, Gavrielli S, Abitbol C, Tau N, Grubstein A, Neiman V, Yosef L, Atar E, Zer A. Association between multitarget tyrosine kinase inhibitors and changes in CT appearance of submucosal fat in the gastrointestinal tract. TUMORI JOURNAL 2021; 107:432-439. [PMID: 33594961 DOI: 10.1177/0300891621995893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Submucosal fat deposition (SMF) in the gastrointestinal tract can be seen in patients treated with vascular endothelial growth factor receptor multitarget tyrosine kinase inhibitors (mtTKIs). We aimed to assess the association between mtTKIs treatment and appearance of SMF on computed tomography (CT). METHODS We performed retrospective evaluation of patients who started mtTKI treatment between 2016 and 2018, with a comparison patient cohort treated with single-target tyrosine kinase inhibitors (stTKIs). SMF amount for each gastrointestinal tract segment (stomach, duodenum, jejunum, ileum, terminal ileum, right colon, left colon) was scored as follows: 0 = none; 1 = low amount (<2 mm thick); 2 = high amount (>2 mm layer). For each CT, segment scores were aggregated to create an SMF index (SMFI). Maximal increase in SMFI between pretreatment and posttreatment CTs was documented. SMF ⩾3 was defined as positive. RESULTS Forty patients treated with mtTKIs and 23 patients receiving stTKIs were included. Maximal increase in SMFI during treatment was 0-1 in 56/63 patients (89%) and 3-6 in 7/63 patients (11%). All patients with positive SMFI received mtTKIs compared to 0 patients treated with stTKIs (17.5% vs. 0%; p = 0.04). mtTKI treatment was associated with higher incidence of nausea/vomiting (4/7) and diarrhea (4/7) when positive SMF was noted, as compared to patients with negative SMF (6/33 patients each; p = 0.048). CONCLUSION Gastrointestinal tract SMF deposition occurs in a considerable proportion of patients treated with mtTKIs with association to abdominal symptoms. This may be unique to mtTKIs and was not found in patients receiving stTKIs.
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Affiliation(s)
- Shlomit Tamir
- Department of Diagnostic Imaging, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Gavrielli
- Department of Diagnostic Imaging, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chen Abitbol
- Department of Diagnostic Imaging, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Tau
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
| | - Ahuva Grubstein
- Department of Diagnostic Imaging, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Neiman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Lilach Yosef
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Eli Atar
- Department of Diagnostic Imaging, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alona Zer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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2
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Sun X, Shen W, Chen X, Wen T, Duan Y, Wang R. Primary intestinal lymphangiectasia: Multiple detector computed tomography findings after direct lymphangiography. J Med Imaging Radiat Oncol 2017; 61:607-613. [PMID: 28345300 DOI: 10.1111/1754-9485.12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 02/22/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION To analyse the findings of multiple detector computed tomography (MDCT) after direct lymphangiography in primary intestinal lymphangiectasia (PIL). METHODS Fifty-five patients with PIL were retrospectively reviewed. All patients underwent MDCT after direct lymphangiography. The pathologies of 16 patients were confirmed by surgery and the remaining 39 patients were confirmed by gastroendoscopy and/or capsule endoscopy. RESULTS After direct lymphangiography, MDCT found intra- and extraintestinal as well as lymphatic vessel abnormalities. Among the intra- and extraintestinal disorders, 49 patients had varying degrees of intestinal dilatation, 46 had small bowel wall thickening, 9 had pleural and pericardial effusions, 21 had ascites, 41 had mesenteric oedema, 20 had mesenteric nodules and 9 had abdominal lymphatic cysts. Features of lymphatic vessel abnormalities included intestinal trunk reflux (43.6%, n = 24), lumbar trunk reflux (89.1%, n = 49), pleural and pulmonary lymph reflux (14.5%, n = 8), pericardial and mediastinal lymph reflux (16.4%, n = 9), mediastinal and pulmonary lymph reflux (18.2%, n = 10), and thoracic duct outlet obstruction (90.9%, n = 50). CONCLUSIONS Multiple detector computed tomography after direct lymphangiography provides a safe and accurate examination method and is an excellent tool for the diagnosis of PIL.
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Affiliation(s)
- Xiaoli Sun
- Department of CT, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Wenbin Shen
- Department of surgery, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Xiaobai Chen
- Department of CT, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Tingguo Wen
- Department of CT, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Yongli Duan
- Department of CT, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
| | - Rengui Wang
- Department of CT, Beijing Shijitan Hospital, Capital Medical University, Haidian District, Beijing, China
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3
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Nay J, Menias CO, Mellnick VM, Balfe DM. Gastrointestinal manifestations of systemic disease: a multimodality review. ACTA ACUST UNITED AC 2016; 40:1926-43. [PMID: 25548008 DOI: 10.1007/s00261-014-0334-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Systemic diseases have many different presentations, including imaging findings in the bowel. Recognizing the imaging findings in these diseases is important in making the correct diagnosis. Although certain imaging features overlap, knowledge of specific findings along with the clinical presentation aid in narrowing the differential or in making an imaging diagnosis. The pictorial review will focus on the gastrointestinal manifestations of systemic diseases, including amyloidosis, angiotensin converter enzyme inhibitor-induced angioedema, celiac sprue, distal intestinal obstruction syndrome, graft-versus-host disease, hemolytic uremic syndrome, hemophilia, Henoch-Schönlein purpura, intestinal lymphangiectasia, mastocytosis, scleroderma, systemic lupus erythematosus, Wegener's granulomatosis, and Whipple's disease. The aforementioned diseases can be subdivided based upon the underlying process leading to the disease. The diseases discussed are categorized into autoimmune, infiltrative, treatment related, congenital/hereditary, and infectious etiologies.
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Affiliation(s)
- John Nay
- Washington University School of Medicine Mallinckrodt Institute of Radiology, 510 S. Kingshighway Blvd, Saint Louis, MO, 63110, USA,
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4
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Katz DS, Scheirey CD, Bordia R, Hines JJ, Javors BR, Scholz FJ. Computed Tomography of Miscellaneous Regional and Diffuse Small Bowel Disorders. Radiol Clin North Am 2013. [DOI: 10.1016/j.rcl.2012.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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5
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Steines JC, Larson JH, Wilkinson N, Kirby P, Goodheart MJ. Intestinal lymphangiectasia mimicking primary peritoneal carcinoma. Am J Obstet Gynecol 2010; 203:e9-e11. [PMID: 20801422 DOI: 10.1016/j.ajog.2010.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 06/29/2010] [Accepted: 07/12/2010] [Indexed: 12/17/2022]
Abstract
Intestinal lymphangiectasia is an obstruction of the lymphatic system. We report on a patient with mesenteric adenopathy and an elevated CA125 level, which were suspicious for peritoneal carcinoma. Further evaluation and bowel resection identified intestinal lymphangiectasia. This disease should be considered in patients with mesenteric adenopathy and a small bowel mass.
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Abstract
This article presents the differential diagnosis for small bowel ischemia. Clinical presentation of small bowel ischemia is variable, presenting with a myriad of specific or nonspecific clinical and laboratory findings. The imaging findings associated with small bowel ischemia are variable and combinations of findings may be necessary for definitive diagnosis. More specific imaging findings in patients with acute small intestine ischemia include bowel wall gas, mesenteric vessel occlusion, mesenteric venous gas, portal venous gas, or absence of bowel wall enhancement. Less specific imaging findings include small bowel wall thickening, mesenteric stranding, and mesenteric fluid. Further complicating the issue, several small intestinal disease processes may mimic ischemia both clinically and radiographically. These alternate diagnoses include infectious, inflammatory, and infiltrative processes.
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7
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Neuromuscular alterations in the dilated ileum of an adult patient with segmental lymphangiectasia. Eur J Gastroenterol Hepatol 2008; 20:935-8. [PMID: 18794610 DOI: 10.1097/meg.0b013e3282f5dda4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Intestinal lymphangiectasia is a rare condition, which is characterized by the dilation of small bowel lymphatics and presents with signs and symptoms of protein-losing enteropathy. Some patients have complained of occlusive symptoms attributable to the mechanical obstruction caused by the considerable mucosal edema associated with the lymphatic dilation. On the basis of the hypothesis that alterations in the neuromuscular structures controlling clearance function or gut tone may play a role in ileal dilation, we examined the resected ileum of a 48-year-old male patient with segmental lymphangiectasia histologically, immunohistochemically (for S100 protein, PGP 9.5, Bcl-2, neuron-specific enolase, neurofilaments, synaptophysin, and CD117/C-kit), and by means of electron microscopy. Histology showed pseudocystic dilation of the mucosal, submucosal, and muscular lymphatics with fragmentation of the circular and longitudinal muscle layers. Hardly any neural expression of synaptophysin was observed, but the neural structures were otherwise morphologically normal and reacted normally to the other neural markers. This case shows that neuromuscular alterations can be found in the dilated ileum of patients with segmental lymphangiectasia.
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5%' and 2*3*8=6*8 and '3d5x'!='3d5x%] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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9
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5'"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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10
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5'||'] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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11
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5����%2527%2522\'\"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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12
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5" and 2*3*8=6*8 and "lme6"="lme6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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13
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-58ixwp1ha] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 DOI: 10.1186/1750-1172-3-5' and 2*3*8=6*8 and '9soh'='9soh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 01/29/2024] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann's disease). Orphanet J Rare Dis 2008; 3:5. [PMID: 18294365 PMCID: PMC2288596 DOI: 10.1186/1750-1172-3-5] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 02/22/2008] [Indexed: 12/13/2022] Open
Abstract
Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool α1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Centre de référence des maladies vasculaires rares, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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Chen S, Harisinghani MG, Wittenberg J. Small bowel CT fat density target sign in chronic radiation enteritis. ACTA ACUST UNITED AC 2004; 47:450-2. [PMID: 14641202 DOI: 10.1046/j.1440-1673.2003.01219.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
On CT, a thickened intestinal wall configured with a middle layer of low attenuation surrounded on each side by layers of higher attenuation has been termed the target sign. The presence of fat within the submucosal layer of the small intestine is a well-known manifestation of Crohn's disease, but has not been reported in other chronic intestinal diseases. We describe CT findings of fat density target sign in a patient with prior radiation.
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Affiliation(s)
- Steven Chen
- Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA 02114, USA
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Mazzie JP, Maslin PI, Moy L, Price AP, Katz DS. Congenital intestinal lymphangiectasia: CT demonstration in a young child. Clin Imaging 2003; 27:330-2. [PMID: 12932684 DOI: 10.1016/s0899-7071(02)00588-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There have been few reports of the CT findings of intestinal lymphangiectasia in adults, and no CT descriptions have been reported in the literature in children. We describe the CT appearance of a biopsy-proven case of primary small intestinal lymphangiectasia in a 3-year-old boy, and we will review the limited literature on the CT findings in this disorder in adults.
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Affiliation(s)
- Joseph P Mazzie
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY 11501, USA
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Affiliation(s)
- Dal Mo Yang
- Department of Radiology, Gachon Medical College, Gil Medical Center, 1198, Guwol-Dong, Namdong-Gu, Inchon, 405-760, South Korea
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Holzknecht N, Helmberger T, Beuers U, Rust C, Wiebecke B, Reiser M. Cross-sectional imaging findings in congenital intestinal lymphangiectasia. J Comput Assist Tomogr 2002; 26:526-8. [PMID: 12218814 DOI: 10.1097/00004728-200207000-00009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A 37-year-old woman presented with an 18 month history of recurrent severe abdominal pain, recurrent diarrhea since her second year of life, and mild peripheral edema. CT and more clearly MRI revealed signs of small bowel and mesenterial edema with partial tubular appearance, which correlated well with the histopathologic findings shown in duodenal biopsy. This is the first report of MR findings in congenital intestinal lymphangiectasia with correlation with other imaging modalities.
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Affiliation(s)
- Nicolaus Holzknecht
- Department of Clinical Radiology, University Hospital of Munich, Munich, Germany.
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Uğuralp S, Mutus M, Kutlu O, Cetin S, Baysal T, Mizrak B. Primary intestinal lymphangiectasia: a rare disease in the differential diagnosis of acute abdomen. J Pediatr Gastroenterol Nutr 2001; 33:508-10. [PMID: 11698774 DOI: 10.1097/00005176-200110000-00019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- S Uğuralp
- Department of Pediatric Surgery, Turgut Ozal Medical Center, Malatya, Turkey.
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Del Campo L, Arribas I, Valbuena M, Maté J, Moreno-Otero R. Spiral CT findings in active and remission phases in patients with Crohn disease. J Comput Assist Tomogr 2001; 25:792-7. [PMID: 11584242 DOI: 10.1097/00004728-200109000-00020] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the radiologic findings in helical CT (HCT) that can be useful to differentiate patients with active Crohn disease (CD) from those in the remission phase. METHOD Fifty patients diagnosed with cases of CD were classified into active or remission phases (n = 37 and n = 13, respectively) according to clinical criteria and laboratory data. All of them underwent an abdominal HCT exploration. The following radiologic findings were evaluated: thickness, density and enhancement of the bowel wall, presence of "target" or "double halo," mesenteric involvement, and possible complications. RESULTS All patients in the active phase had pathologic findings on HCT. The wall thickness was 8.5 (SD 3.2) and 6.5 mm (SD 4 mm) in active and remission phases, respectively (p = 0.06). Target was present in seven patients (19%) with active disease and in five patients (38.5%) in the remission phase (p = 0.15). Density of the wall in the active phase was 95 HU and in the remission phase 65 HU (p < 0.002). Mesentery was involved in 89.2% of patients in the active phase and 38% of patients in the remission phase (p < 0.001). The complications observed in patients with active-phase disease were abscesses in nine (24%), phlegmons in two, fistulas in three, intestinal obstruction in two, and pancreatitis in one. CONCLUSION A normal HCT rules out that a patient with CD is in the active phase of disease. The presence of significant bowel wall enhancement and mesentery involvement assists in the differentiation of patients in the active phase from those in remission. HCT is also effective to assess the presence of complications, which are indicative of the active phase.
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Affiliation(s)
- L Del Campo
- Service of Radiology, Hospital de la Princesa, Universidad Autónoma, Madrid, Spain
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