Inflammation The body’s response to disease

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Lymphatic Considerations of the Abdomen/Pelvis in the Hospitalized

PatientPatientHugh Ettlinger, DO, FAAOHugh Ettlinger, DO, FAAO

“If this be true we must “If this be true we must keep them normal all keep them normal all the time or see confused the time or see confused nature in the form of nature in the form of disease, the list through. disease, the list through. Thus we strike at the Thus we strike at the source of life and death source of life and death when we go to the when we go to the lymphatics.”lymphatics.” A.T. Still Philosophy of A.T. Still Philosophy of

Osteopathy, p 108 Osteopathy, p 108

The body’s response to disease

Local Local –– InflammationInflammation

Humeral Humeral –– ImmuneImmune

Nervous SystemNervous System Spinal cord reflexesSpinal cord reflexes Nervous System Nervous System –– Spinal cord reflexesSpinal cord reflexes

Central Central –– Hypothalamic/pituitary/adrenal Hypothalamic/pituitary/adrenal axisaxis

Inflammation

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Role of lymphatics in inflammation Antigen Antigen –– the lymphatics carry antigen to the lymphatics carry antigen to

the lymph nodes where the immune the lymph nodes where the immune response is initiated. This is particularly response is initiated. This is particularly p p yp p yimportant in infections.important in infections.

Role of lymphatics in inflammation

Circulatory ConsiderationsCirculatory Considerations

Circulation

Inflammation Inflammation produces a change produces a change in capillary in capillary permeability which permeability which allows a large allows a large protein efflux intoprotein efflux intoprotein efflux into protein efflux into the interstitium.the interstitium.

This produces an This produces an inflammatory inflammatory exudate, which can exudate, which can only be drained via only be drained via the lymphatics.the lymphatics.

Circulation

Inflammation Inflammation produces stasis of produces stasis of local capillaries, so local capillaries, so that all circulation that all circulation from an inflammed from an inflammed tissue is lymphatic.tissue is lymphatic.

Once the tissue Once the tissue becomes saturated becomes saturated with fluid, with fluid, circulation to the circulation to the inflammed tissue inflammed tissue will occur at the will occur at the same rate as same rate as lymphatic drainagelymphatic drainage

If we think and use a If we think and use a homely phrase, and homely phrase, and say that disease is say that disease is only too much dirt in only too much dirt in the wheels of life, the wheels of life, then we will see that then we will see that nature takes this nature takes this method to wash out method to wash out the dirt.the dirt. A.T. Still Philosophy A.T. Still Philosophy

of Osteopathy, p 109 of Osteopathy, p 109

As an application, As an application, pneumonia is too pneumonia is too much dirt in the much dirt in the wheels of the lungs. wheels of the lungs. If so, we must wash If so, we must wash it out; nowhere can it out; nowhere can we go to a better we go to a better place for water than place for water than to the lymphatics.to the lymphatics. A.T. Still Philosophy A.T. Still Philosophy

of Osteopathy, p 109 of Osteopathy, p 109

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Role of lymphatics in inflammation

Resolution of the Inflammatory processResolution of the Inflammatory process

The lymphatics are central to the The lymphatics are central to the progression and resolution of inflammationprogression and resolution of inflammationprogression and resolution of inflammationprogression and resolution of inflammation

Impaired or inadequate lymph drainage is Impaired or inadequate lymph drainage is implicated in chronic inflammatory implicated in chronic inflammatory diseases, as well as fibroic diseasesdiseases, as well as fibroic diseases

Resolution of the inflammatory process Many if not most inflammatory mediators Many if not most inflammatory mediators

are broken down in the systemic circulation. are broken down in the systemic circulation. They are brought there by the local They are brought there by the local y g yy g ylymphatic drainage.lymphatic drainage.

The progression and ultimate resolution of The progression and ultimate resolution of the inflammatory process with healing will the inflammatory process with healing will depend on efficient lymphatic drainage.depend on efficient lymphatic drainage.

Resolution of the inflammatory process Neutrophils are responsible for the Neutrophils are responsible for the

lysozymes that produce most of the tissue lysozymes that produce most of the tissue damage during inflammationdamage during inflammationg gg g

Their removal is critical to resolution of Their removal is critical to resolution of inflammation. They are removed by inflammation. They are removed by macrophages which phagocytise themmacrophages which phagocytise them

These macrophages are removed from the These macrophages are removed from the tissue via lymphatic drainage.tissue via lymphatic drainage.

Thus it behooves us Thus it behooves us to handle them with to handle them with care, for by and from care, for by and from them a withered limb, them a withered limb, organ or and division organ or and division of the body receives of the body receives what we callwhat we callwhat we call what we call reconstruction, or is reconstruction, or is builded anew.builded anew.

A.T. Still A.T. Still Philosophy of Philosophy of Osteopathy, p. 105Osteopathy, p. 105

Mechanics of the lymph circulation Terminal Terminal –– drainage of thoracic duct into drainage of thoracic duct into

the subclavian vein.the subclavian vein.

VascularVascular –– the movement of lymph throughthe movement of lymph through Vascular Vascular the movement of lymph through the movement of lymph through the lymphatic vessels.the lymphatic vessels.

Formation Formation –– the movement of extracellular the movement of extracellular fluid into the initial lymphaticfluid into the initial lymphatic

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Mechanics of the lymph circulation Terminal Terminal –– drainage of thoracic duct into drainage of thoracic duct into

the subclavian vein.the subclavian vein.

The Respiratory/Circulatory modelThe Respiratory/Circulatory model –– J.J. The Respiratory/Circulatory model The Respiratory/Circulatory model J. J. Gordon Zink, DOGordon Zink, DO

“The cardiogenic aspect of circulation depends on “The cardiogenic aspect of circulation depends on the respirogenic aspect of circulation to complete the respirogenic aspect of circulation to complete the circuit. But that is not all; the most important the circuit. But that is not all; the most important feature is the fact that ‘terminal’ lymphatic feature is the fact that ‘terminal’ lymphatic drainage into the venous system is also dependent drainage into the venous system is also dependent on this effective diaphragmatic respiration when on this effective diaphragmatic respiration when h i i i ”h i i i ”the patient is resting.”the patient is resting.”

J. Gordon Zinc, Respiratory and Circulatory care: J. Gordon Zinc, Respiratory and Circulatory care: The Conceptual Model, Osteopathic Annals, 1977 The Conceptual Model, Osteopathic Annals, 1977 p. 11p. 11

Terminal lymph drainage

Respiratory/circulatory functionRespiratory/circulatory function

J. Gordon ZinkJ. Gordon Zink

35 35 –– 60% of thoracic duct flow is 60% of thoracic duct flow is produced by respirationproduced by respiration

Pressure changes in the thoraxPressure changes in the thorax

Relation of crus to cysterna chyleRelation of crus to cysterna chyle

Venturi effect Venturi effect

Effect on lymph formationEffect on lymph formation

Terminal lymph drainage

Schad H, Flowaczny H, Brechtelsbauer H, Schad H, Flowaczny H, Brechtelsbauer H, Birkenfeld G. 1978. The significance of Birkenfeld G. 1978. The significance of respiration for thoracic duct flow in relation respiration for thoracic duct flow in relation to other driving forces of lymph flowto other driving forces of lymph flowto other driving forces of lymph flow. to other driving forces of lymph flow. Pflugers Arch 378(2):121Pflugers Arch 378(2):121--5.5.

Dumont AE. 1975. The flow capacity of the Dumont AE. 1975. The flow capacity of the thoracic ductthoracic duct--venous junction. Am J Med venous junction. Am J Med Sci 269(3):292Sci 269(3):292--301.301.

Negative intrathoracic pressures produced by respiratory excursionsexcursions move venous and lymphatic fluid back to the heart.

Central Lymph

The venturi effect:

The entrance of the thoracic duct at the t o ac c duct at t ejunction of two central veins reduces the pressure against which lymph must drain.

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Central Lymph

• Crura act as pump for cysterna chyle.

• Crura may obstruct flow when tense (goat and boulder parable)

“The treatment of the lymphatic system must “The treatment of the lymphatic system must always begin by securing ‘terminal drainage’ by always begin by securing ‘terminal drainage’ by way of insuring a good abdominothoracic way of insuring a good abdominothoracic venous pump. Venous stasis may precede venous pump. Venous stasis may precede lymph blockage, but it is the lymphatic lymph blockage, but it is the lymphatic disturbance that spells disaster to the tissues.”disturbance that spells disaster to the tissues.”

J. Gordon Zinc, DO The Osteopathic Holistic J. Gordon Zinc, DO The Osteopathic Holistic Approach to Homeostasis, AAO Yearbook, Approach to Homeostasis, AAO Yearbook, 1970, p. 41970, p. 4

Vascular Lymph Flow

“The lymph stream is readily checked in “The lymph stream is readily checked in many ways. The vessels are pliable and many ways. The vessels are pliable and readily compressed.”readily compressed.”y py p

F.P. Millard, DO Applied Anatomy of the F.P. Millard, DO Applied Anatomy of the Lymphatics, 1922. p. 43 Lymphatics, 1922. p. 43

Vascular lymph flow

Lymphangion Lymphangion –– a unit a unit with smooth muscle and with smooth muscle and valvesvalves

Vascular lymph flow


Has intrinsic peristaltic Has intrinsic peristaltic actionaction

Vascular lymph flow



Can generate enough Can generate enough g gg gpressure to account for pressure to account for all intravascular lymph all intravascular lymph movement movement

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Vascular lymph flow



Can generate enough Can generate enough g gg gpressure to account for pressure to account for all intravascular lymph all intravascular lymph movement movement

Can be obstructed with Can be obstructed with increased tissue increased tissue tension/somatic tension/somatic dysfunctiondysfunction

Vascular lymph flow

Eisenhoffer, et. al. Effect Eisenhoffer, et. al. Effect of Outflow pressure on of Outflow pressure on lymphatic pumping in lymphatic pumping in vitro Am. J. of vitro Am. J. of Physiology 265, 1993Physiology 265, 1993

Aukland & Reed. Aukland & Reed. I i i lI i i l l h il h iInterstitialInterstitial--lymphatic lymphatic Mechanisms in the Mechanisms in the control of Extracellular control of Extracellular fluid volumes Physio. fluid volumes Physio. Reviews 73, 1993Reviews 73, 1993

Vascular lymph flow


Has intrinsic peristaltic Has intrinsic peristaltic action with a pacemakeraction with a pacemaker

Vascular lymph flow



Mechanical and Mechanical and electrical couplingelectrical coupling Electrical Electrical ––

spontaneous, rapid, spontaneous, rapid, propagates in both propagates in both directionsdirections

Mechanical Mechanical –– Filling Filling stimulates pacemaker stimulates pacemaker via stretch, slow, via stretch, slow, unidirectionalunidirectional

Vascular lymph flow

Mechanical and Mechanical and electrical couplingelectrical coupling

Filling dependentFilling dependent NO pacemaker NO pacemaker

activity without fillingactivity without filling Filling stimulates bothFilling stimulates both Filling stimulates both Filling stimulates both

pacemakerspacemakers Contraction frequency Contraction frequency

is dependent on the is dependent on the rate of perfusion rate of perfusion

Vascular lymph flow

Mechanical and Mechanical and electrical couplingelectrical coupling Crowe MJ, Von dW, Crowe MJ, Von dW,

Brock JA, Van Brock JA, Van Helden DF. 1997. CoHelden DF. 1997. Co--ordination of ordination of

il i i iil i i icontractile activity in contractile activity in guineaguinea--pig mesenteric pig mesenteric lymphatics. J Physiol lymphatics. J Physiol (Lond ) 500(1):235(Lond ) 500(1):235--44.44.

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Vascular lymph flow



Sympathetic InnervationSympathetic Innervationy py p Alpha receptor Alpha receptor

dominantdominant Will increase Will increase

contractilitycontractility

Vascular lymph flow

Sympathetic InnervationSympathetic Innervation Effect is small enough Effect is small enough

that researchers suggest that researchers suggest the innervation is more the innervation is more to modulate immune to modulate immune function than affect function than affect flflflowflow

McHale NG. 1992. The McHale NG. 1992. The lymphatic circulation. Ir lymphatic circulation. Ir J Med Sci 161(8):483J Med Sci 161(8):483--6.6.

Vascular lymph flow



Sympathetic InnervationSympathetic Innervationy py p Alpha receptor Alpha receptor

dominantdominant Will increase Will increase

contractilitycontractility Humoral influencesHumoral influences

Vascular Lymph Flow

Lymphangion Lymphangion –– a unit with smooth muscle and a unit with smooth muscle and valves.valves.

Has intrinsic peristaltic activity with pacemaker.Has intrinsic peristaltic activity with pacemaker.

Able to account for all movement of lymphAble to account for all movement of lymph Able to account for all movement of lymph Able to account for all movement of lymph through the vessels.through the vessels.

Vascular Lymph Flow

The “path of drainage” should be evaluated and The “path of drainage” should be evaluated and any dysfunctions which may be reducing lymph any dysfunctions which may be reducing lymph flow should be treated, before any “lymph flow should be treated, before any “lymph pump” techniques are initiated.pump” techniques are initiated.p p qp p q

For each region, there will be “key areas” where For each region, there will be “key areas” where the vessels are most vulnerablethe vessels are most vulnerable

The most effective means of increasing lymph The most effective means of increasing lymph flow is to promote it’s formationflow is to promote it’s formation

Lymph Formation

There is a small uphill hydrostatic gradient There is a small uphill hydrostatic gradient which must be overcome for extracellular which must be overcome for extracellular fluid to move into an initial lymphatic fluid to move into an initial lymphatic y py p

This may be the limiting factor in overall This may be the limiting factor in overall lymph flowlymph flow

External forces are necessary for lymph External forces are necessary for lymph formation.formation.

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Circulatory forces (the hydrostatic and osmotic gradients which produce capillary exchange) p y g )dissipate almost immediately beyond the edge of the vessel.

These (starling) forces do not account for the movement of fluid through the interstitial matrix (gel) where cellular respiration takes placetakes place

By the time fluid reaches the lymphatic, there is actually a small uphill gradient which must be overcome for lymph to form.

There is an interstitial mechanism, which includes tissue movement and fluctuation of extracellular fluid, that functions to promote interstitial interchange and facilitate cellular respiration

Lymphatics develop in the interstitial space, and in the presence of this interstitial mechanism, and develop and adapt to utilize these forces for the formation of lymph

Anchoring filaments

produce a change in volume with alternating movements in themovements in the local interstitial tissue.

Respiratory excursions produceproduce lymph in the lungs

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Peristaltic contractions, as well

t f thas movement of the diaphragm forms lymph in the abdomen

Overlapping endothelial cells

Allow the ebb and flow of a fluid fluctuation to move fluid from the interstitium to the lymphatics

Arterial pulse creates a small fluctuation of fluid in the immediate vicinity of the arterioles Manythe arterioles. Many lymphatics are found in this area. Pulse has been shown to produce lymph in these vessels.

“The definition of the word fluctuation in my concept is that which is in Webster’s dictionary, ‘the movement of a fluid within a natural of artificial cavity andartificial cavity and observed by palpation of percussion.’ ”

W.G. Sutherland, TSO p.13

Lymph Formation

There is a small uphill hydrostatic gradient There is a small uphill hydrostatic gradient which must be overcome for extracellular which must be overcome for extracellular fluid to move into an initial lymphatic fluid to move into an initial lymphatic

This may be the limiting factor in overall This may be the limiting factor in overall lymph flowlymph flow

External forces are necessary for lymph External forces are necessary for lymph formation.formation.

This is where the “lymph pump” is appliedThis is where the “lymph pump” is applied

Lymph Pump

A well designed study demonstrated lymph pump A well designed study demonstrated lymph pump to be vastly more effective increasing lymph flow to be vastly more effective increasing lymph flow when done over the area of swelling, ie. Lymph when done over the area of swelling, ie. Lymph formation, compared to the area of vascular flow. formation, compared to the area of vascular flow.

McGeown, et.al. The role of External McGeown, et.al. The role of External Compression and Movment in Lymph Propulsion Compression and Movment in Lymph Propulsion in the Sheep Hindlimb J Phys (london) 387, 1987in the Sheep Hindlimb J Phys (london) 387, 1987

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Lymph Pump

The effect on lymph flow was rate and amplitude The effect on lymph flow was rate and amplitude dependent. dependent.

McGeown, JG, et. al Effects of Varying Patterns McGeown, JG, et. al Effects of Varying Patterns of External Compression on Lymph Flow in the of External Compression on Lymph Flow in the Hindlinb of Anaesthetized Sheep J Physio Hindlinb of Anaesthetized Sheep J Physio (London) 397, 1988(London) 397, 1988

Regional Lymph Drainage

Abdomino/Pelvic peritoneal drainageAbdomino/Pelvic peritoneal drainage

Gastrointestinal Lymph drainageGastrointestinal Lymph drainage

Genitourinary Lymph drainageGenitourinary Lymph drainage Genitourinary Lymph drainageGenitourinary Lymph drainage

The Abdomen/Pelvis is a single container, that serves and supports the function of the GI and GU systems.

It’s roof is the Diaphragm, floor is the pelvic diaphragm, with significant support from the posterior abdominal wall.

The Diaphragm as a Sponge

Peritoneal fluid Peritoneal fluid drains upward to drains upward to the undersurface the undersurface of the diaphragmof the diaphragm


Peritoneal fluid Peritoneal fluid drains upward to drains upward to the undersurface the undersurface of the diaphragmof the diaphragm


StomataStomata

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LacuneLacune


Prelymphatic Prelymphatic channelschannels


Drain to Drain to Cysterna Cysterna ChyleChyleyy

Drainage of the GI System

3 regions, based on 3 regions, based on development (foregut, development (foregut, midgut, hindgut)midgut, hindgut)

CeliacCeliac Celiac Celiac

Superior mesentericSuperior mesenteric

Inferior MesentericInferior Mesenteric

All neurovascular All neurovascular structures enter and exit structures enter and exit through the mesenteriesthrough the mesenteries


CeliacCeliac


Superior Superior MesentericMesenteric

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Inferior Inferior MesentericMesenteric

Vascular lymph flow

Can be obstructed Can be obstructed with increased tissue with increased tissue tension/somatic tension/somatic dysfunction.dysfunction.

The GI system drains The GI system drains through the roots of through the roots of the mesenteriesthe mesenteries

Vascular lymph flow

Can be obstructed Can be obstructed with increased tissue with increased tissue tension/somatic tension/somatic dysfunction.dysfunction.

The GI system drains The GI system drains through the roots of through the roots of the mesenteriesthe mesenteries

Central Lymph

• Fluid ends up in the Aortic nodes on the posterior wall, then enter the Cyeterna ChyleChyle.

• The GI system accounts for > 50% of all lymph flow

Drainage of the GU System

Reproductive Reproductive organsorgans

Most drain toMost drain to Most drain to Most drain to External and External and internal iliac internal iliac nodes, then on to nodes, then on to Aortic ascending Aortic ascending to Cysterna to Cysterna ChyleChyle



The perineum, asThe perineum, as The perineum, as The perineum, as well as cervix well as cervix and lower uterus and lower uterus have drainage have drainage pathways to the pathways to the inguinal nodesinguinal nodes

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Urinary systemUrinary system

The kidneys drain to The kidneys drain to the hilum, then followthe hilum, then followthe hilum, then follow the hilum, then follow the renal vein where the renal vein where they join the drainage they join the drainage from the upper ureters from the upper ureters at the aortic nodes, at the aortic nodes, which eventually end which eventually end at Cysterna Chyle.at Cysterna Chyle.


Urinary systemUrinary system

The lower ureter and The lower ureter and bladder drain to thebladder drain to thebladder drain to the bladder drain to the internal and external internal and external iliac nodes, then up to iliac nodes, then up to the aorta and cysterna the aorta and cysterna chylechyle

The Diaphragm as a Sponge Lymphatic Fluids Lymphatic Fluids

converging at the converging at the DiaphragmDiaphragm

PeritonealPeritoneal PeritonealPeritoneal

Gut tubeGut tube

Posterior body Posterior body wallwall

PelvisPelvis

Lower ExtremityLower Extremity

Central Lymph

Respiration involves Respiration involves coordinated action coordinated action of the diaphragm, of the diaphragm, pelvic diaphragm, pelvic diaphragm, anterior andanterior andanterior and anterior and posterior abdominal posterior abdominal walls.walls.

Lymph rises to Lymph rises to cysterna chyle along cysterna chyle along the psoasthe psoas

Clinical Considerations


Millard usedMillard used Millard used Millard used exam of the exam of the inguinal nodes as inguinal nodes as a means of a means of distinguishing distinguishing PID from PID from appendicitisappendicitis


Millard Millard “I have based my “I have based my

diagnosis… as to the diagnosis… as to the appendix upon the stateappendix upon the stateappendix upon the state appendix upon the state in which I found the in which I found the Inguinal nodes” Inguinal nodes”

“…the almost set type “…the almost set type of glandular inguinal of glandular inguinal enlargement found in enlargement found in Gonorrhea”Gonorrhea”

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Fibroid UterusFibroid Uterus

PIDPID

EndometriosisEndometriosis EndometriosisEndometriosis

ProstitisProstitis


PyelonephritisPyelonephritis

NephrolithiasisNephrolithiasis

?Chronic kidney?Chronic kidney ?Chronic kidney ?Chronic kidney diseasedisease

Clinical Considerations CholecystitisCholecystitis

HepatitisHepatitis

Gastritis/ulcerGastritis/ulcerGastritis/ulcerGastritis/ulcer

DiverticulitisDiverticulitis

AppendicitisAppendicitis

POSTPOST--OPOP

All Acute illnessesAll Acute illnesses

Chronic illnessesChronic illnesses


Inflammatory Bowel DiseaseInflammatory Bowel Disease

Obstruction of Intestinal lymphatics produces Obstruction of Intestinal lymphatics produces bowel changes strikingly similar to IBDbowel changes strikingly similar to IBD

Witte CL, Witte MH. 1984. Lymphatics in the Witte CL, Witte MH. 1984. Lymphatics in the pathophysiology of edema. In: Johston MG, pathophysiology of edema. In: Johston MG, editor. Experimental biology of the lymphatic editor. Experimental biology of the lymphatic circulation. New York: Elsevier; p 167circulation. New York: Elsevier; p 167--88.88.

Kalima, T.V. Experimental regional Enteritis in Kalima, T.V. Experimental regional Enteritis in Pigs. 1976. Scand. J of Gastroenterology. 11. Pigs. 1976. Scand. J of Gastroenterology. 11. 353 353 -- 362362



Histologic studies consistantly show mesenteric Histologic studies consistantly show mesenteric lymphatics obstructed in Crohn’s diseaselymphatics obstructed in Crohn’s disease

Heatley, et. al. (1980) Mesenteric lymphatic Heatley, et. al. (1980) Mesenteric lymphatic obstruction in Cohn’s Disease. Digestion, 20. obstruction in Cohn’s Disease. Digestion, 20. 307 307 –– 313.313.



Numerous Authors have theorized that IBD is a Numerous Authors have theorized that IBD is a consequence of Lymph obstruction and/or consequence of Lymph obstruction and/or dysfunction.dysfunction.

The theory is that gut inflammation leads to The theory is that gut inflammation leads to fibrosis with consequent lymphatic obstruction, fibrosis with consequent lymphatic obstruction, which leads to recurrent, more severe which leads to recurrent, more severe inflammation and subsequent bowel damage.inflammation and subsequent bowel damage.

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Witte CL, Witte MH. 1984. Lymphatics in the Witte CL, Witte MH. 1984. Lymphatics in the pathophysiology of edema. In: Johston MG, pathophysiology of edema. In: Johston MG, editor. Experimental biology of the lymphatic editor. Experimental biology of the lymphatic i l ti N Y k El i 167i l ti N Y k El i 167 8888circulation. New York: Elsevier; p 167circulation. New York: Elsevier; p 167--88.88.

Kalima, T.V. Experimental regional Enteritis in Kalima, T.V. Experimental regional Enteritis in Pigs. 1976. Scand. J of Gastroenterology. 11. Pigs. 1976. Scand. J of Gastroenterology. 11. 353 353 -- 362362

Tonelli, P. (2000) New Developments in Crohn’s Tonelli, P. (2000) New Developments in Crohn’s Disease. Chirurgia Italiana (52) 109Disease. Chirurgia Italiana (52) 109--121121


PancreatitisPancreatitis

In normal functioning, pancreatic lymphatics do In normal functioning, pancreatic lymphatics do not carry pancreatic enzymes or insulinnot carry pancreatic enzymes or insulin

During experimntal pancreatitis, pancreatic During experimntal pancreatitis, pancreatic enzymes are found in high concentrations in enzymes are found in high concentrations in lymph effluent.lymph effluent.

Dumont, et. al. 1960 Lymphatic pathways of Dumont, et. al. 1960 Lymphatic pathways of pancreatic secretion in man. Annals of Surgery pancreatic secretion in man. Annals of Surgery 152. 403152. 403



Obliteration of Pancreatic lymph vessels can lead Obliteration of Pancreatic lymph vessels can lead to fatal necrotic pancreatitisto fatal necrotic pancreatitis

Alexander, J.S. et.al. Gastrointestinal Alexander, J.S. et.al. Gastrointestinal Lymphatics in Health and Disease. From Lymphatics in Health and Disease. From Pathophysiology, 2009 Elsevier Pathophysiology, 2009 Elsevier



Lymph drainage has been shown to dramatically Lymph drainage has been shown to dramatically reduce the tissue damaging effects of pancreatic reduce the tissue damaging effects of pancreatic enzymes with obstruction of the main pancreatic enzymes with obstruction of the main pancreatic d t i dd t i dduct in dogs.duct in dogs.

Witte CL, Witte MH. 1984. Lymphatics in the Witte CL, Witte MH. 1984. Lymphatics in the pathophysiology of edema. In: Johston MG, pathophysiology of edema. In: Johston MG, editor. Experimental biology of the lymphatic editor. Experimental biology of the lymphatic circulation. New York: Elsevier; p 167circulation. New York: Elsevier; p 167--88. 88.



In chronic pancreatitis, there is evidence of In chronic pancreatitis, there is evidence of fibrosis with obliteration of lymphatics, reducing fibrosis with obliteration of lymphatics, reducing the capacity of lymph drainage of the pancreas, the capacity of lymph drainage of the pancreas,

t ti ll di i t d/ i i tht ti ll di i t d/ i i thpotentially predisposing to and/or increasing the potentially predisposing to and/or increasing the severity of future attacksseverity of future attacks

O’Morchoe, Charles. 1997. Lymphatic O’Morchoe, Charles. 1997. Lymphatic System of the Pancreas. Microscopic Research System of the Pancreas. Microscopic Research and Technique. 37: 456and Technique. 37: 456--477 477

The science of osteopathy is simple. You realize you are a mechanic of the fluids of the body, as well as of the skeletal system.

W.G. Sutherland, TSO p.127

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Without this Without this cautious procedure, cautious procedure, you’re patient had you’re patient had better save his life better save his life and money by and money by passing you by as a passing you by as a failure, until you failure, until you

b k l db k l dare by knowledge are by knowledge qualified to deal qualified to deal with the lymphatics.with the lymphatics. A.T. Still A.T. Still

Philosophy of Philosophy of Osteopathy, p 105Osteopathy, p 105

Inflammation The body’s response to disease

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