Colon Cancer Prevention

Colon Cancer Prevention: Is it the Fiber or the Phytates?

on May 21st, 2015


Dietary factors are considered the most important environmental risk factors for cancer. Within recent years, a large number of naturally occurring health-enhancing substances of plant origin known as phytonutrients have been recognized to have beneficial effects on certain cancers. Beans, chickpeas, split peas and lentils are packed with all sorts of wonderful nutrients, but the reason they may protect against several degenerative diseases may be due to non-nutritive compounds, or even so-called “antinutrient” compounds like phytates.

Phytates have a somewhat negative reputation for binding to certain minerals (like iron, zinc and manganese) and slowing their absorption. But they have also been found to offer anti-inflammatory health benefits. “The reputation of phytate has had a roller coaster ride ever since its discovery; it has undergone alternate eminence and infamy.” (I previously explored the surprising new science about phytates in my video Phytates for the Prevention of Osteoporosis). Could they play a potential role in preventing colon cancer?

In the U.S., colon cancer is the second leading cause of cancer death, but some parts of the world have had just a tiny fraction of our rates, with the highest rates reported in Connecticut, and the lowest in Kampala, Uganda. The famous surgeon Denis Burkitt spent 24 years in Uganda and most of the hospitals he contacted there had never seen a case of colon cancer. Noting they live off diets centered on whole plant foods, he figured that maybe it was the fiber that was so protective.

Some studies have called that interpretation into question. Danes appear to have more colon cancer than Finns, yet Danes consume almost twice the dietary fiber. What else, then, could explain the low cancer rates among plant-based populations? Well, fiber isn’t the only thing found in whole plant foods, but missing from processed and animal foods. Maybe it’s the phytate.

Dietary phytate, rather than fiber per se, may be the most important variable governing the frequency of colon cancer, as phytate is known to be a powerful inhibitor of the iron-mediated production of hydroxyl radicals, a particularly dangerous type of free radical. So the standard American diet may be a double whammy, the heme iron in muscle meat plus the lack of phytate in refined plant foods to extinguish the iron radicals.

This may account for what researchers found in the Adventist study, highlighted in my video, Phytates for the Prevention of Cancer. They found excess risk of cancer for higher intakes of both red meat and white meat, suggesting all meats contribute to colon cancer formation — about twice the risk for red meat eaters, and three times the risk for those eating chicken and fish.

Those who eat meat could reduce their risk in two ways: by cutting down on meat or by eating more beans, an excellent source of phytates.

So it’s not just how much meat we eat, but our meat to vegetables ratio. Between the two extremes (high-vegetable and low-meat diets versus high-meat and low-vegetable diets) a risk ratio of about eight appears to exist, sufficient to explain a substantial part of the international variation in the incidence of colorectal cancer. Those with the worst of both worlds, high meat and low vegetable, were at eight times the risk.

More on colon cancer in Stool Size Matters.

Here are a few of my latest videos on the latest wonders of the musical fruit:

What about that music, though? See my blog Beans and Gas: Clearing the air.

What about soybeans and cancer? See Breast Cancer Survival and Soy and BRCA Breast Cancer Genes and Soy.

Other ways to mediate the effects of meat intake can be found in my video Reducing Cancer Risk in Meateaters.

For more about how phytates may play a role in both cancer prevention and treatment see Phytates for Rehabilitating Cancer Cells and Phytates for the Treatment of Cancer.

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live year-in-review presentations Uprooting the Leading Causes of Death, More Than an Apple a Day, and From Table to Able.

Image Credit: Ton Rulkens / Flickr

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The Dangers of Cow’s Milk

child


The Dangers of Cow’s Milk
by Linda Folden Palmer, D.C.
Today, many of the problems parents have with their babies are linked to new parenting and feeding techniques that have been implemented during the recent century. Colic, for instance, is far more common in the U.S. than in many other places around the world. Two chief causes for its rise are the stress suffered by babies being regularly separated from their mothers, and the common difficulties babies have tolerating the large cow’s milk proteins in infant formulas and breastfeeding mothers’ diets. Cow’s milk is a foreign substance that has pervaded every corner of our diets – starting with artificial infant feeds, but finding its way into mother’s breastmilk through the foods she eats as well. As it turns out, health problems such as childhood diabetes, obesity, bowel disease, osteoporosis, heart disease, cataracts, colic, ear infections, hyperactivity, and cancer, on the rise in both children and adults, can be strongly linked to infant feeding choices.While there are literally thousands of research studies, each revealing at least one of milk’s hazards, the dairy industry goes to great lengths to stifle any damaging rumors. Blanket statements, such as, “There is simply no scientific research to back up these claims,” are easily made. With a long and successful history of dairy promotion, these are readily accepted by the public. More people need to go to the real research and learn the truth for themselves. They should be very suspicious of these foreign foods being pushed on their children. They should question motives as well as possible outcomes. Although some of the dangers of cow’s milk consumption relate more to adults than to children, parents’ actions form the basis for lifelong dairy-consuming habits in their children.

The harmful components of cow’s milk include all the major parts of it, as well as some more minor elements. Lactose is a sugar meant for babies, but it’s generally harmful to adults. When adults DO breakdown lactose, the resultant galactose can cause vision, prostate, and other problems in older adults. The proteins in cow’s milk are different from human milk proteins and cause problems of digestion, intolerance, impaired absorption of other nutrients, and autoimmune reactions. Few of the proteins meant for baby cows are found naturally in human mother’s milk, and none are found in any natural adult human food. Even the high protein content in cow’s milk creates problems. Human babies need the saturated fats and cholesterol in mother’s milk. Bovine milk fat is not appropriately composed for human babies and is only deleterious to the health of children and adults. Cow hormones are not meant for humans, and older children and adults are not meant to consume hormones. And, cows have been selectively bred over time to create high levels of these hormones – those being the cows that grow the fastest and produce the greatest amount of milk. Cows also concentrate pesticides and pollutants into their milk fat, from their high dietary food and water requirements. The high amount of drugs now given to cows adds to this chemical soup. But we need milk to build strong bones, don’t we? Actually, heavy milk consumption is associated with increased osteoporosis.

Deflating Dairy

The highly promoted idea that milk builds strong bones refers to the prevention of osteoporosis – this is the reason for strengthening bones. Decades of effort to demonstrate that high calcium diets chiefly derived from dairy products build strong bones have failed to prove any such correlation. In fact, the opposite seems to be true.1 It appears that high calcium intake before puberty, and especially in young childhood, may have some slight positive effect on bones, but this diet is not the answer. A balanced intake of all the bone minerals, along with adequate vitamin A, C, D, and K, is what is truly needed. A balanced intake of minerals cannot occur when the diet emphasizes dairy. Dairy’s high calcium causes relative deficiencies in magnesium and other bone-building minerals, and its high phosphorus and animal protein reduces calcium availability. Physical activity has the greatest benefit for bones – the body efficiently uses what is available to build strong bones when it senses the need. Human milk and vegetable sources are superior to dairy for calcium and other nutrients in many ways. There are fewer nutritional or other health advantages to giving cow’s milk to children than is generally believed, while there are certainly many risks.

Almost every day another health research finding is made about whole grains, a serving of vegetables, two fruits per day, cashews, legumes, fish, or some other food, other than milk that is, and their connection to a reduced risk of heart disease, breast cancer, stroke, diabetes, or other disease. This is because cow’s milk and its derivatives today make up one-third of the adult diet, and half to two-thirds of caloric intake in children, thus replacing so much other important, nutritious food needed in the diet. This leads to insufficient intake of important vitamins, several minerals, and healthy fiber and vegetable oils. Cancer-preventing antioxidants in foods are missing in this milk diet as well. While one form of antioxidant vitamin A is added to milk (but not all dairy products), it is likely counteracted by the pesticide and drug residues. The full complement of vitamin A and associated enzymes, found in vegetables and other foods, are required for cancer prevention. Many, many more kinds of antioxidants are found in vegetables, legumes, fruits, and grains.

No other animal in the animal kingdom drinks milk beyond childhood. No other animal suffers from osteoporosis, except the occasional pet raised on human meals.

If there remains a desire to provide milk to a child who has no diarrhea, rashes, or other intolerance reactions, organic raw whole milk would be the best choice. In raw (unpasteurized) milk there will be healthy flora, and more active forms of immune agents. In organic milk there are fewer antibiotic residues, no added hormones, and cows are given better feeds. It is not true that raw milk contains helpful lactase enzyme. Only curdled or other high-bacteria versions will contain some; produced by the bacteria. Commercial raw milks can contain a leukemia virus, but this virus cannot perpetuate among drug-free raw milk cow sources. Goat’s milk is considered by many to be superior in many ways. Much less documented information is available about goat’s milk, but it appears that the proteins are less problematic for digestion, although allergic intolerance to these can also occur. Lactose and natural hormones remain issues in goat milk although, to date, goats apparently are not injected with extra growth hormone.

Although it was apparent from day one that formula was a health risk for infants, back when it was first promoted, cow’s milk for older children appeared to be a nutritional manna. And with one or two glasses a day from a healthy, range-fed animal, it likely nearly was. Since this time, however, the quality of dairy has drastically reduced while its consumption has exploded… with a massive amount of advertising help. The evidence suggesting that the early faith in milk was misplaced has been building up for decades. The dairy industry has had to take increasingly extreme efforts to keep this information out of public awareness.

I have only touched on the tip of the existing evidence against the health claims of the milk industry promoters. Since our childhood, the dairy industry has worked hard to have dairy products enshrined in a food group of their own. Even though they were given their own space in the new Eating Right food pyramid, they found themselves placed in a small upper portion and have lobbied to have the pyramid withdrawn.2 Many nutrition experts such as Harvard’s Dr. Walter Willett3 suggest they should not be a featured group in the pyramid at all. The dairy industry has also successfully convinced many vegetarians that milk from cows is a vegetarian food. Since few substantiated health claims can be made anymore, the milk industry’s most recent promotion has recently been to simply show their product on the upper lip of celebrities of all kinds, even those who are dairy-allergic (Bill Clinton), and even on those who are too young to be consuming whole milk (the Rugrats). Before this promo, it was simply “Got milk?” While an ever-growing preponderance of scientific information points to the dangers of cow’s milk, favorable public and even mainstream medical opinion about dairy products has been very successfully maintained.

Knowing and avoiding the potentially harmful effects that high dairy consumption and milk-sensitivity reactions can have on your child is just as important and loving as nursing, close bonding, and informed health care decisions. What we feed our children matters; how we parent them matters. These measures will lead to the best health, comfort and happiness available to a child. Parents have the power to create and enjoy healthier, happier children with brighter futures.

Far more information on the dangers of cow’s milk, with over 100 science journal references, can be found in Dr. Linda Palmer’s book: The Baby Bond: The New Science Behind What’s Really Important When Caring for Your Baby.

1 L. H. Kushi et al., “Health Implications of Mediterranean Diets in Light of Contemporary Knowledge. 1. Plant Foods and Dairy Products,” Am J Clin Nutr 61, suppl 6 (Jun 1995): 1407 S-1415S.2 M. Nestle, “Food Lobbies, the Food Pyramid, and U.S. Nutrition Policy,” Int J Health Serv 23, no. 3 (1993): 483-96.

3 W. C. Willett, Department of Nutrition, Harvard School of Public Health, in the Boston Globe, June 8, 1999.

See also “The Deadly Influence of Formula in America“.

Excerpted with permission of the author from Baby Matters: What Your Doctor May Not Tell You About Caring for Your Baby by Dr. Linda Palmer.

6 Gross Causes of Food Borne Illness

Updated May 06, 2015.

Written or reviewed by a board-certified physician. See About.com’sMedical Review Board.

It seems every few months we hear of another product that has been recalled due to contamination with one thing or another. Most contaminants cause upset stomach and symptoms similar to those of a stomach bug. But some people end up with serious complications or even die from these outbreaks.

Learn more about common contaminants that often lead to widespread food recalls.

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E. coli magnified x7000. PASIEKA/Science Photo Library/Getty Images

1.  E. Coli – Escherichia Coli

E. coli is one of the most well known causes of food borne illness and product recalls in the US. It actually isn’t even in the top 5 pathogens that cause food borne illness though.   More »

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Salmonella bacterium. Science Picture Company/Getty Images

2.  Salmonella

Salmonella is the leading cause of hospitalization and deaths from food borne illness in the United States. It is also the second most common pathogen leading to illness from food. It doesn’t just occur in undercooked chicken either. Read up on this dangerous bacteria so you know how to protect yourself.  More »

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Listeria monocytogenes. Science Picture Company/Getty Images

3.  Listeria

Listeria is commonly found in raw milk and processed deli meats or hot dogs. Lately it has been found even in commercially prepared items such asBlue Bell Ice Cream – which prompted a complete recall of all products by the company in April 2015. Although listeriosis is uncommon in healthy people, it poses serious risks to pregnant women, older adults, infants and people with compromised immune systems. More »

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Norovirus – or Norwalk virus. Science Picture Company/Getty Images

4.  Norovirus

Norovirus is a highly contagious pathogen that can affect many people in a short amount of time. It is the leading cause of food borne illness in the United States. Once known as the “cruise ship virus” because of the frequency of outbreaks on cruise ships – this virus is now one of the most common causes of “stomach flu”. It spreads quickly and is especially contagious in areas where many people are in close quarters – such as on cruise ships or in college dorms.  More »

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Campylobacter jejuni. BSIP/Universal Images Group/Getty Images

5.  Campylobacter

Campylobacter is a common cause of food borne illness but it typically occurs in isolated incidents and does not prompt large recalls. Symptoms include vomiting, diarrhea (may be bloody), cramping, abdominal pain and fever. These symptoms usually appear 2 to 5 days after exposure to the bacteria. It is more common during the summer and a vast majority of people that get it recover without treatment. It is most serious for people with compromised immune systems.

Most cases of campylobacter occur from eating raw or undercooked poultry. It’s often spread by cutting raw meat on a cutting board and then reusing the same cutting board for produce. According to the CDC, there can be enough campylobacter in just one drop of raw poultry juice to infect a person. More »

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Toxoplasma gondii. BSIP/Universal Images Group/Getty Images

6.  Toxoplasma Gondii

It is estimated that 60 million of us (in the United States alone) are currently infected with the Toxoplasma parasite. Luckily, most of us will never know it because it doesn’t make us sick. When your immune system is functioning properly it keeps the parasite from making you sick. Unfortunately, people with compromised immune systems and pregnant women are at higher risk for illness from this bug.

The toxoplasma parasite can be found on raw or undercooked meats such as pork, venison or lamb as well as in contaminated water. A common source of infection is cat feces. If you have ever been pregnant and warned not to change or touch cat litter – toxoplasmosis is why.

Those who do get sick with toxoplasmosis may experience “flu-like” symptoms with swollen glands and muscle aches that can last for over a month.  More »

Blood, Lymphatic, and Immune Systems

Chapters 5 and 6

Objectives

  • Recognize and use terms related to the anatomy and physiology of blood, lymphatic, and immune systems.
  • Recognize and use terms related to the pathology of the blood, lymphatic, and immune systems.
  • Recognize and use terms related to the diagnostic procedures for the blood, lymphatic, and immune systems.
  • Recognize and use terms related to the therapeutic interventions for the blood, lymphatic, and immune systems.

Functions of the Blood, Lymphatic, and Immune Systems

Homeostasis, or a “steady state,” is a continual balancing act of the body systems to provide an internal environment that is comparable with life. The two liquid tissues of the body, the blood and lymph have separate but interrelated functions in maintaining this balance. They combine with a third system, the immune, to protect the body against pathogens that could threaten the organism’s viability. The blood is responsible for the following:

  • Transportation of gases (oxygen O2) and carbon dioxide (CO2), chemical substances (hormones, nutrients, salts), and cells that defend the body.
  • Regulation of the body’s fluid and electrolyte balance, acid-base balance, and body temperature.
  • Protection of the body from infection.
  • Protection of the body from loss of blood by the action of clotting.

The lymph system is responsible for the following:

  • Cleansing the cellular environment
  • Returning proteins and tissue fluids to the blood (drainage)
  • Providing a pathway for the absorption of fats and fat-soluble vitamins into the bloodstream.
  • Defending the body against disease.

The immune system is responsible for the following:

  • Defending the body against disease via the immune response

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The hematic and lymphatic systems flow through separate yet interconnected and interdependent channels. Both are systems composed of vessels and the liquids that flow through them. The immune system, a very complex set of levels of protection for the body, includes blood and lymph cells.

The above graphic shows the relationship of the lymphatic vessels to the circulatory system. Note the the close relationship between the distribution the distribution of the lymphatic vessels and the venous blood vessels. Tissue fluid is drained by the lymphatic capillaries and transported by a series of larger lymphatic vessels toward the heart.

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 Hematic System

The hematic system is composed of blood and the vessels that carry the blood throughout the body. Because blood can be an extremely important part of the diagnostic process, students need to understand its normal composition. Blood is composed of a solid portion called plasma. Blood cells make up 45% of the total blood volume, and plasma makes up the other 55%.

The solid portion of blood is composed of three different types of cells:

  • Erythrocytes – also called red blood cells (RBCs).
  • Leukocytes – also called white blood cells (ABCs).
  • Thrombocytes – also called clotting cells, cell fragments, or platelets. Be Careful!

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 Components of Blood

Erythrocytes (Red Blood Cells)

The erythrocytes (which are normally present in the millions) have the important function of transport O2 and CO2throughout the body. The vehicle for this transportation is a protein-iron pigment called hemoglobin.

The formation of RBCs in the bone marrow is stimulated by a hormone from the kidneys called erythropoietin. RBCs have a life span of approximately 120 days, after which they decompose into hemosiderin, an iron pigment resulting from hemolysis and bilirubin. The iron is stored in the liver to be recycled into new RBCs, and the bile pigments are excreted via the liver.

Abnormal RBCs can be named by their morphology, the study of shape or form. RBCs normally have a biconcave, dislike shape. (Although the center is depressed, there is not an actual hole.) Those that are shaped differently often have difficulty in carrying out their function. For example, sickle cell anemia is a hereditary condition characterized by erythrocytes (RBCs) that are abnormally shaped. They resemble a crescent or sickle. An abnormal hemoglobin found inside these erythrocytes causes sickle-cell anemia in a number of Africans and African-Americans. Did You Know?

Leukocytes (White Blood Cells)

Although there are fewer leukocytes (thousands, not millions), there are different types with different functions. In general, WBCs protect the body from invasion by pathogens. The different types of cells provide this defense in a number of different ways. There are two main types of WBCs: granulocytes and agranulocytes.

Granulocytes

Named for their appearance, granulocytes also called polymorphonucleocytes have small grains within the cytoplasm and multilobed nuclei. Both names are used interchangeably.

These are three types of granulocytes, each with its own function. Each of them is named for the type of dye that it attracts.

  1. Eosinophils – are cells that absorb an acidic dye, causing them to appear reddish. An increase in eosinophils is a response to a need for their function in defending the body against allergens and parasites.
  2. Neutrophils are cells that do not absorb either an acidic or basic dye and consequently are a purplish color. They are also called phagocytes because they specialize in phagocytosis and generally combat bacteria in pyogenic infections. This means that these cells are drawn to the site of a pathogenic “invasion,” where they consume the enemy and remove the debris resulting from the battle.
  3. Basophils are cells that absorb a basic (or alkaline) dye and stain a bluish color. Especially effective in combating parasites, they release histamine (a substance that initiates an inflammatory response) and heparin (an anticoagulant), both of which are instrumental in healing damaged tissue.

Be Careful!

Be Careful!

Agranulocytes

Agranulocytes are cells named for their lack of granules. The alternative names, mononuclear leucocytes, is so given because they have one nucleus. Both names are used interchangeably. Although these cells originate in the bone marrow, they mature after entering the lymphatic system. There are two types of these WBCs:

  1. Monocytes: These cells, named for their single, large nucleus, transform into macrophages, which eat pathogens and are effective against severe infections.
  2. Lymphocytes: these cells are key in what is called the immune response, which involves the “recognition” of dangerous, foreign (viral) substances, and the manufacture of their neutralizers. The foreign substances are called antigens, and the neutralizers are called antibodies

Thrombocytes (Platelets)

Platelets (also known as thrombocytes) have a round or oval shape and are so named because they look like small plates. Platelets aid in the process of coagulation, the process of changing a liquid to a solid. When blood cells escape their normal vessels, they agglutinate, or clump together, by the following process: First, they release factor X (formerly called thrombokinase), which, in the presence of calcium, reacts with the blood protein, prothrombin, to form thrombin. Thrombin then converts another blood protein, fibrinogen, to fibrin, which eventually forms a mesh like fibrin clot (blood clot), achieving hemostasis (control of blood flow; that is, stopping the bleeding).

Plasma

Plasma, the liquid portion of blood, is composed of the following:

  1. Water, or H2O (90%)
  2. Inorganic substances (calcium, potassium, sodium)
  3. Organic substances (glucose, amino acids, fats, cholesterol, hormones)
  4. Waste products (urea, uric acid, ammonia, creatinine)
  5. Plasma proteins (serum albumin, serum globulin, and two clotting proteins: fibrinogen and prothrombin)

Serum is plasma minus the clotting proteins. Serology is the branch of laboratory medicine that studies blood serum for evidence of infection by evaluating antigen-antibody reactions in vitro.

Did You Know

The clotting process

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Blood Groups

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Human blood is divided into four major different types: A, B, Ab, and O. The differences are due to antigens present on the surface of the blood cells. Antigens are substances that produce an immune reaction by their nature of being perceived as foreign to the body. In response, the body produces substances called antibodiesthat nullify or neutralize the antigens. In blood, these antigens are called agglutinogens because their presence can cause the blood to clot.

The antibody is termed an agglutinin. For example, type A blood has A antigen, type B has B antigen, type AB has both A and B antigens, and type O has neither A nor B antigens. If an individual with type A blood is transfused with type B blood, The A antigens will form anti-B antibodies because they perceive B blood as being foreign. Following the logic of each of these antigen-antibody reactions, an individual with type AB blood is a universal recipient, and an individual with type O blood is a universal donor.

Another antigen, the Rh factor, is important in pregnancy because a mismatch between the fetus and the mother can cause erythroblastosis fetalis, or hemolytic disease of the newborn. In this disorder, a mother with a negative Rh factor will develop antibodies to an RH + fetus during the first pregnancy. If another pregnancy occurs with an Rh + fetus, the antibodies will destroy the fetal blood cells.

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Lymphatic System

The lymphatic system is responsible for the following:

  • Cleansing the cellular environment
  • Returning proteins and tissue fluids to the blood
  • Providing a pathway for the absorption of fats into the bloodstream
  • Defending the body against disease

The lymphatic system is composed of lymph (or interstitial fluid), lymph vessels, lymph nodes, lymph organs (e.g. tonsils, adenoids, appendix, spleen,, thymus gland, and patches of tissue in the intestines called Peyer patches), and lymphoid tissue. Monocytes and lymphocytes pass from the bloodstream through the blood capillary walls into the spaces between the cells in the body. When they pass into this lymph or interstitial fluid that surrounds cells, they perform their protective functions. Monocytes change into macrophages, destroy pathogens, and collect debris from damaged cells. Lymphocytes are much more complicated and are essential to the immune response, so they are discussed in the next section. Once monocytes and lymphocytes pass into the lymphatic capillaries, the fluid is termed lymph orlymphatic fluid.

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Lymph moves in one directo to prevent pathogens from flowing through the entire body. The system filters out the microorganisms as the lymph passes through its various capillaries, vessels, and nodes. Lymph travels in the following sequence:

  1. From the interstitial spaces between the cells, then
  2. Toward the heart through lymphatic capillaries.
  3. To lymphatic vessels that carry lymph using a valvular system.
  4. To the lymphatic nodes, which are also called lymph glands, that filter the debris that has been collected through the use of macrophages. These nodes can become enlarged when pathogens are present. Note the major lymph nodes in the figure, including the cervical, axillary, inguinal , and mediastinal nodes.
  5. Then to either the right lymphatic duct or the thoracic duct, both of which empty into the large subclavian veins in the neck.
  6. Once in the venous blood, the lymph is then recycled through the body through the circulatory system.

The organs in the lymphatic system are the spleen, the thymus gland, the tonsils, the appendix, and Peyer’s patches. the spleen is located in the upper left quadrant and serves to filter, store, and produce blood cells; remove RBCs; and activate B lymphocytes. The thymus gland is located is located in the mediastinum and is instrumental in the development of T lymphocytes (T cells). the tonsils are lymphatic tissue (lingual, pharyngeal, and palatine) that helps protect the entrance to the respiratory and digestive systems. The vermiform appendix and Peyer patches are lymphoid tissue in the intestines.

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Immune System

The immune system is composed of organs, tissues, cells, and chemical messengers that interact to protect the body from external invaders and its own internally altered cells. The chemical messengers are cytokines which are secreted by cells of the immune system that direct immune cellular interactions. Lymphocytes (leukocytes that are categorized as either B cells or T cells) secrete lymphokines. Monocytes and macrophages secrete monokines. Interleukins are a type of cytokine that send messages among leukocytes to direct protective action. The best way to understand this system is through the body’s various levels of defense. The goal of pathogens is to breach these levels to enter the body, reproduce, and subsequently exploit healthy tissue, causing harm. The immune system’s task is to stop them.

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The above graphic illustrates the levels of defense. The two outside circles represent nonspecific immunity and its two levels of defense. the inner circle represents the various mechanisms of specific immunity, which can be natural (genetic) or acquired in four different ways. Most pathogens can be contained by the first two lines of nonspecific defense. However, some pathogens deserve a “special” means of protection, which is discussed under “Specific Immunity.”

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Nonspecific Immunity

This term refers to the various ways that the body protects itself from many types of pathogens, without having to “recognize” them. The first line of defense in nonspecific immunity (the outermost layer) consists of the methods of protection:

  • Mechanical – examples include the skin, which acts as a barrier, and the sticky mucus on mucous membranes, which serves to trap pathogens.
  • Physical – examples include coughing, sneezing, vomiting, and diarrhea. Although not pleasant, these serve to expel pathogens that have gotten past the initial barriers.
  • Chemical – examples include tears, saliva, and perspiration. These have a slightly acidic nature that deters pathogens from entering the body while also washing them away. In addition, stomach acids and enzymes serve to kill germs.

The second line of defense in nonspecific immunity comes into play if the pathogens make it past the first line. Defensive measures include certain processes, proteins, and specialized cells. Defensive processes include the following:

  • Phagocytosis – pathogens that make it past the first line of defense and enter into the bloodstream may be consumed by neutrophils and monocytes.
  • Inflammation – acquiring its name from its properties, this is a protective response to irritation or injury. The characteristics (heat, swelling, redness, and pain) arise in response to an immediate vasoconstriction, followed by an increase in vascular permeability. These provide a good environment for health. If caused by a pathogen, the inflammation is called an infection.
  • Pyrexia – when infection is present, fever may serve a protective function by increasing the action of phagocytes and decreasing the viability of certain pathogens.

The protective proteins are part of the second line of defense. These include interferons, which get their name from their ability to “interfere” with viral replication and limit a virus’s ability to damage the body. A second protein type, the complement proteins, exist as inactive forms in blood circulation that become activated in the presence of bacteria, enabling them to lyse (destroy) the organisms.

Finally the last of the “team” in the second line of defense are the natural killer (NK) cells. This special kind of lymphocyte acts nonspecifically to kill cells that have been infected by certain viruses and cancer cells.

Specific Immunity

Specific immunity may be either genetic – an inherited ability to resist certain diseases because of one’s species, race, sex, or individual genetics – or acquired. Specific immunity is dependent on the body’s ability to identify a pathogen and prepare a specific response (antibody) to only that invader (antigen). antibodies are also referred to as immunoglobulins (lg). The acquired form can be further divided into natural and artificial forms, which in turn can each be either active or passive. After a description of the specific immune process, each of the four types is discussed. Did You Know?

Specific immunity is dependent on the agraulocytes (lymphocytes and monocytes) for its function. The monocytes metamorphose into macrophages, which dispose of foreign substances. The lymphocytes differentiate into either T lymphocytes (they mature in the thymus) or B lymphocytes (they mature in the bone marrow or fetal liver). Although both types of lympocytes take part in specific immunity, they do it in different ways.

The T cells neutralize their enemies through a process of cell-mediated immunity. This means that they attack antigens directly. They are effective against fungi, cancer cells, protozoa, and unfortunately, organ transplants. B cells use a process of humoral immunity (also called antibody-mediated immunity). This means that they secrete antibodies to “poison” their enemies.

Types of Acquired Immunity

Acquired immunity is categorized as active or passive and then is further subcategorized as natural or artificial. All describe ways that the body has acquired antibodies to specific diseases.

Active acquired immunity can take either of the following two forms:

  1. Natural: Development of memory cells to protect the individual from a second exposure.
  2. Artificial: Vaccination (immunization) that uses a greatly weakened form of the antigen, thus enabling the body to develop antibodies in response to this intentional exposure. Examples are the DTP and MMR vaccines.

Passive acquired immunity can take either of the following two forms:

  1. Natural: Passage of antibodies through the placenta or breast milk.
  2. Artificial: Use of immunoglobulins harvested from a donor who developed resistance against specific antigens

Disorders of the lymph circulation: their relevance to anaesthesia and intensive care

  1. A. Mallick and
  2. A. R. Bodenham*

+Author Affiliations


  1. Department of Anaesthesia, Leeds General Infirmary, United Leeds Teaching Hospitals, Leeds LS1 3EX, UK
  1. Corresponding author. E‐mail: andy.bodenham@leedsth.nhs.uk

Abstract

The lymphatic system is known to perform three major functions in the body: drainage of excess interstitial fluid and proteins back to the systemic circulation; regulation of immune responses by both cellular and humoral mechanisms; and absorption of lipids from the intestine. Lymphatic disorders are seen following malignancy, congenital malformations, thoracic and abdominal surgery, trauma, and infectious diseases. They can occasionally cause mortality, and frequently morbidity and cosmetic disfiguration. Many lymphatic disorders are encountered in the operating theatre and critical care settings. Disorders of the lymphatic circulation relevant to anaesthesia and intensive care medicine are discussed in this review.

Br J Anaesth 2003; 91: 265–72

Key words

Exchange of fluid and movement of macromolecules across the systemic capillaries are governed by Starling forces and capillary permeability. In healthy tissues, small volumes of fluid are filtered continuously into the interstitial tissues. The lymphatic circulation forms an accessory pathway to return this excess fluid and proteins from the tissue spaces back to the blood stream. This fluid is called lymph. Lymph contains a large number of lymphocytes, macrophages, and small amounts of plasma proteins including coagulation factors. The lymphatic circulation starts from blind‐ended lymphatic capillaries and ends at the subclavian veins. In disease states with altered Starling forces and increased capillary permeability, the amount of fluid filtered out of the systemic capillaries may greatly increase in volume and overwhelm this system to produce oedema.

Disturbances of the lymph circulation are less well recognized than those of the arterial and venous circulation. The lymphatic vessels, unlike the arteries and veins, are not easily seen during dissection or surgery.66Damage to the lymphatics is generally not followed by any obvious immediate consequences and it is often believed that they are expendable in surgical practice. In the clinical setting, lymphatic pathways can be disrupted by many different causes including congenital anomalies, infection, malignancy, radiation, surgery, and trauma. The effects of blockage/leakage become problematic when the usual compensatory mechanisms are overwhelmed.

Applied anatomy

In the human body the lymphatic system is organized in the form of lymphatic vessels, lymph nodules, and nodes. The lymphatic vessels begin as blind‐ended lymphatic capillaries. They branch and interconnect freely and extend into almost all tissues in parallel with systemic capillaries, with the exception of the central nervous system, eyes, and certain cartilaginous structures. These anatomical areas have other forms of fluid circulation, in the form of the cerebrospinal fluid, aqueous and vitreous humour, and the synovial fluid of joints respectively.

Lymphatic capillaries join to form lymph venules and veins that drain via regional lymph nodes into the thoracic duct on the left side or the right lymphatic duct. The lymph from the major portion of the body flows through the thoracic duct while that from the right upper quadrant drains into the right lymphatic duct.

Dynamics of lymph flow

The lymphatic circulation is devoid of any central pump. Lymph flow depends, predominantly, on local pressure effects and intrinsic contraction of the larger lymphatics. Any factor that increases the interstitial tissue pressure by 2 mm Hg tends to increase lymph flow in lymphatic vessels. Conversely, if the interstitial tissue pressure is greater than 2 mm Hg above atmospheric pressure, then lymph flow may decrease as a result of compression of the lymphatic vessels. The anterograde flow of lymph is further facilitated by the presence of numerous microscopic and macroscopic bi‐leaflet valves, which exist at least every few millimetres to prevent retrograde flow. To achieve a continuous local lymph output, external intermittent compression of the lymphatics is essential from: (i) contraction of muscles; (ii) movement of body parts; (iii) arterial pulsations; and (iv) compression of the tissues by forces outside the body.

Lymph veins have contractile smooth muscles and the segment of the vessel between successive valves is called a lymphangion. The lymphangion contracts when it is stretched with lymph and empties proximally into successive lymphangions. The contraction of a lymphangion can generate a pressure as high as 25 mm Hg.

The exact mechanisms of lymphatic smooth muscle contractility are unclear. Sympathomimetic agents,42including alpha and beta agonists, appear to mediate lymphatic truncal contraction, as do the by‐products of arachidonic acid including thromboxane and prostaglandins.30 There is evidence for the presence of G proteins, adenyl cyclase, and phospholipase C activities in lymphatic smooth muscle cell membranes.31 Lymphatic endothelial cells produce nitric oxide,48 that in turn relaxes lymphatic smooth muscles, via accumulation of guanosine 3′, 5′ cyclic monophosphate. Angiotensin II65appears to increase lymph flow by a direct effect on lymphatic vessels, while 5‐hydroxytryptamine43 has an opposite action by inhibiting spontaneous contractility.

The contractility of the mesenteric lymphatics is suppressed in a dose‐dependent manner by halothane.1757 The effects of other anaesthetic agents are not known. Stimulation of the greater splanchnic nerve (sympathetic) appears to increase lymphangion contractility and lymph flow.62 It has been shown that increased sympathetic activity gives rise to peripheral lymphoedema, which shows improvement after sympathectomy. This has been proposed to be one mechanism for reflex sympathetic dystrophy and its treatment.28

In the thoracic duct, lymph flow is dependent on: (i) pressure gradients generated by contractile elements in the lymphatics; (ii) the intrathoracic pressure; and (iii) the venous backpressure in the subclavian vein. These interactions have not been studied in any detail, compared with the large amount of work on ventilatory/circulatory interactions in venous and arterial systems. PEEP and positive pressure ventilation appear to increase lymph flow through the thoracic duct. Conversely, excessively high intrathoracic pressure and a high PEEP can impede the thoracic duct flow both by direct pressure on the duct and venous hypertension.24

Lymphatic outflow and pumping have been shown to increase in the setting of hypovolaemic shock in order to restore the blood volume.38 After major burn injury, lymph flow from the injured area increases and transports a large amount of hyaluronan, a connective tissue component of the interstitial matrix.49 Clinical and radiological studies have demonstrated markedly raised thoracic duct flow, with gross dilatation and increased pressures, in patients with cirrhosis. It is not understood whether such changes are a cause or secondary effect of the underlying pathology.

Chyle

Chyle is a mixture of lymph and chylomicrons from intestinal lymphatics. It is normally found in the mesenteric lymphatics, the cisterna chili, and the thoracic duct. The presence of chylomicrons gives chyle its milky white colour. Its characteristics and composition are shown in Table1.59 Chyle normally forms three layers on standing: a creamy top layer, a milky middle layer, and cellular sediment (Fig. 1). It may clot over time. Chyle is strongly bacteriostatic and rarely becomes infected. It contains a large number of lymphocytes without any leukocytes.

Fig 1 Chyle in a bottle from a pleural drain, in the patient whose chest x‐ray is shown in Figure 4. This fluid was photographed 5 days after injury, when the patient was receiving nasogastric feed. The fluid shows three distinct layers on standing.

Table 1

Features of chyle

Normal chyle flow in the thoracic duct of an adult is about 1500–2500 ml day–1. Daily chyle output varies with the level of activity, bowel function, and the fat content of the diet. It can be as low as 10–15 ml h–1 during periods of immobility, starvation, and continuous nasogastric suction, but it can markedly increase after a meal rich in long chain triglycerides. Normally, the liver contributes one‐third of the lymph flow in the thoracic duct in a resting adult. Varying the pressure within the thoracic duct can alter each organ’s contribution to thoracic duct flow and thereby affect the composition of chyle. A raised pressure in the thoracic duct can decrease the lymph flow out of the gut without much effect on the hepatic lymph flow.

Formation of oedema

Oedema results when tissue fluid accumulates faster than the lymphatic system can remove it. Ascites, pleural, and pericardial effusions are localized fluid collections formed by similar mechanisms. Most clinical presentations of oedema are thought to be due, primarily, to disturbances in the arterial or venous circulation, for example the pulmonary oedema seen in heart failure or ARDS. The role of the lymphatics in such disorders has not been well studied clinically because of inherent difficulties in measuring lymph flow. Pulmonary lymph flow has been shown to increase in animal models of ARDS, and has been used as an index of alveolar‐capillary membrane permeability. Lymphatic endothelial cells appear to be affected by the inflammatory process, and histology of lungs from patients with ARDS has shown a marked disruption of lymphatic as well as pulmonary capillaries.63Lymphatic damage may therefore have a role in the pathogenesis of the interstitial oedema of ARDS.

Widespread tissue oedema is common in critically ill patients. Multiple factors are involved including increased systemic capillary permeability, alterations in plasma oncotic forces, and altered lymphatic transport. The exact role of the lymphatics is uncertain. A significantly raised intrathoracic pressure in mechanically ventilated critically ill patients can increase the impedance to lymph flow in the thoracic duct and other larger lymphatics. In addition, alterations in lymphangion contractility and lymphatic capillary permeability may be important in critically ill patients.

Lymphoedema

Lymphoedema is defined as accumulation of lymph in the extracellular space as a result of lymphatic block or dysfunction. Many cases follow chronic lymphatic obstruction but it can develop acutely in any organ following surgery. The early oedema seen in surgically transposed free flaps, or transplanted visceral organs, for example bowel, lungs, and heart, is in part a result of accumulation of lymph as a result of transected lymphatics.55 Surgeons usually make no attempt to anastomose lymphatic vessels during such procedures.

Acute lymphoedema has been shown to affect the heart and lungs following thoracic surgery. It can depress myocardial function and cause pulmonary hypertension as a result of perivascular oedema.12 37 Acute lymphoedema typically settles over a few days and studies have shown early restoration of lymphatic collaterals.

Chronic lymphoedema is usually seen as a complication of radical cancer surgery or radiotherapy in the Western world. In tropical and subtropical countries, filariasis, a parasitic infection, is responsible for lymphoedema in more than 90 million people. Lymph slowly accumulates in the tissues distal to the site of damage over weeks, months or years. In the initial stage the oedema is soft, pitting and temporarily reduced by elevation and a compression bandage (Fig. 2). Pain may occur from stretching of soft tissues and be related to conditions such as infection, thrombosis, and nerve entrapment syndromes. If left untreated, an inflammatory state develops with collagen deposition and soft tissue overgrowth. At this stage, the tissue becomes less pitting, more firm or brawny, and elevation of the limb no longer results in reduction of the oedema.10Superimposed occult or overt infection (lymphangitis) commonly contributes to progressive limb deformity and elephantiasis (Fig. 3).

Fig 2 An adult male with congenital bilateral lower limb lymphoedema, referred because he required bilateral knee replacement. The left side only has been treated by compression bandage therapy (see bandage marks on left lower leg), with impressive reduction in the lymphoedema. Photograph, with patient permission, courtesy of lymphoedema service, Cookridge Hospital, Leeds.

Fig 3 Late trophic changes in a leg following longstanding lymphoedema. So called ‘Elephantiasis’. Photograph, with patient permission, courtesy of lymphoedema service, Cookridge Hospital, Leeds.

Early diagnosis is essential to prevent worsening of the condition and to help relieve the psychological impact of the disease. There is no effective drug treatment. Current options include education of patients in prevention of infection, limb positioning, exercise, compression garments and bandages, pneumatic pumps, and lymphatic massage.10 Prevention of acute inflammation including lymphangitis and cellulitis is crucial as the swelling tends to worsen after each episode. Surgery is occasionally undertaken to de‐bulk excessive tissue or to bypass local lymphatic defects by lympho‐venous anastomosis, in patients with severe deformity. During anaesthesia, neither arterial nor venous cannulation should be attempted in the lymphoedematous limbs. Non‐invasive measurement of arterial pressure is often not possible.

Drug absorption

Protein‐based drugs are broken down when administered by the enteral route and therefore have poor bioavailabilty. Therefore, the s.c. or i.m. route is widely used for delivery of protein drugs. The lymphatics are responsible for the absorption of subcutaneously or intramuscularly injected protein drugs including certain vaccines, human growth hormone and insulin.9 These drugs are not absorbed by the systemic capillaries because of their large molecular size. Liposomes, injected subcutaneously, can potentially act as carriers for the delivery of therapeutic and diagnostic agents for lymphatic disorders.50 Liposomes, on reaching the lymph nodes, will be phagocytosed by the macrophages, releasing the drugs to be concentrated in the lymph nodes. This route of administration may prove useful in the treatment of metastatic malignancies and parasitic infestations including filariasis.

Some oral medications including digoxin may also be absorbed by the mesenteric lymphatics. In a recent case report, a patient who was receiving oral digoxin developed an unrelated chylothorax. The patient’s plasma digoxin concentration was measured as near to zero, but that in chyle, collected from the chylothorax, was at therapeutic levels.58 It is not known which other medications are absorbed via the mesenteric lymphatics into the systemic circulation.

Lymphatics play a major role in systemic dissemination of toxins in cases of snake and spider bites.29 Firm pressure bandaging is an effective means of restricting the lymphatic transport of toxins, provided the bandage is applied within a defined pressure range of 5–9 kPa. Strict limb immobilization is necessary to minimize lymphatic flow, and walking after upper or lower limb envenomation will inevitably result in systemic envenomation despite other first‐aid measures.29

Mesenteric lymph and organ dysfunction

Recently, there has been an increase in the understanding of the gut mucosal barrier, and the pathophysiology of sepsis and multiple organ dysfunction, beyond the original description of bacterial translocation. Bacterial translocation has been shown to occur in animal models but data from human studies are less convincing.13Recent work failed to demonstrate any bacteria or endotoxin in the portal blood, mesenteric lymph, and chyle in patients with multiple organ dysfunction secondary to sepsis or multiple trauma.36 47 54

New reports suggest that mesenteric lymph has a significant role in the generation of remote organ injury in the presence of dysfunctional gut.13 46 Shock, trauma or sepsis‐induced gut injury can result in the generation of cytokines and other pro‐inflammatory mediators in the gut.39 Mesenteric lymph appears to be the route of delivery of inflammatory mediators from the gut to remote organs.38 45 These toxic mediators have been demonstrated in mesenteric lymph,45 but not in the systemic or portal circulation. Acute lung injury,33endothelial damage,63 haemopoietic failure,3 and activation of white cells,2 22 64 68 69 have been shown to be caused by these toxic products carried in mesenteric lymph. Division or ligation of lymphatics in the gut mesentery before induction of shock prevents the increase in lung permeability and limits shock‐induced pulmonary neutrophil recruitment.1 14 53

Thoracic duct drainage has been proposed as a means of removing these substances before they reach the pulmonary and systemic circulation. Preliminary trials in patients with pancreatitis were promising in reducing the severity of acute lung injury.16 This may be because the lung is the first organ exposed to mesenteric lymph. Further work needs to be performed in this area before recommending this approach for clinical use.

Sentinel node biopsy

Sentinel node biopsy is increasingly performed to decide whether a patient requires a regional lymph node clearance following removal of breast or other cancers.5 The sentinel node is the first node to receive lymph from a primary tumour and therefore the most likely to have metastatic cells.4 A blue dye or a radioactive compound is injected around the primary tumour and becomes concentrated in the sentinel node to help in its identification.

Anaesthetists should be aware of some practical implications of this procedure.8 Patent V dye absorbs light wavelength at 640 nm, which corresponds to the wavelength of red light used in pulse oximeters. When this dye ultimately reaches blood, the percentage of deoxygenated haemoglobin is overestimated, that is the pulse oximeter reads a lower SpO2 than the actual value.52This decrease in SpO2 reading can occur between 30 s to 20 min following injection, and can last several hours.8 52Arterial blood gas analysis is recommended during the procedure. There are reports of other adverse reactions to patent V dye including: anaphylactic and anaphylactoid reactions;67 discolouration of urine; and tattooing of skin around the injection site.8

Other lymphatic disorders

Disorders associated with the lymphatic system are principally seen in relation to congenital malformations, the spread of infection or invasion by tumour cells, and the effects of lymphatic obstruction or leak.

Airway compromise

Many lymphatic tumours including lymphomas progressively enlarge without any pain or tenderness and are often noticed first in the neck. They can present as symptomatic or asymptomatic mediastinal masses. They can result in upper and lower airway compression,25 26as well as superior vena caval obstruction. The anaesthetic implications of these conditions have been reviewed.15Induction of anaesthesia can result in the ‘cannot intubate, cannot ventilate’ situation or complete loss of the airway.60 Some slow growing lymphatic tumours including lymphangiomas can involve several organs in the neck and the mediastinum and can present with acute airway obstruction because of encroachment on the tongue base, parapharyngeal space, or the larynx.26 Cystic hygroma is a lymphatic tumour seen in infants and children, and airway management remains a challenge during induction of anaesthesia.32

Chylothorax

Chylothorax is defined as an accumulation of chyle within a pleural cavity. A milky appearance of pleural fluid is considered typical. The condition results from either obstruction or damage of the central lymphatics, including the thoracic duct or cisterna chyli. Such damage can result from trauma, or surgery involving the oesophagus, thoracic spine, and aorta. Traumatic chylothorax is seen after blunt or penetrating chest injuries (Fig. 4). A significant number of such cases can be associated with a fracture dislocation of the thoracic spine.56 Sudden hyperextension of the spine has been suggested as the cause of thoracic duct injury in this setting. Spontaneous chylothorax has been reported after minor trauma such as coughing or stretching following ingestion of a fatty meal.

Fig 4 Chest x‐ray from an adult male with blunt chest trauma following severe deceleration injury in a road traffic accident. Multiple ribs fractures are seen on the left side (arrows). There are signs of left lung contusion and a left sided chest drain has been inserted to remove pleural fluid. A left thoracotomy and thoracic duct ligation was carried out after 10 days, when chyle loss was persistently greater than 3 litre day–1. This procedure cured his chyle leak.

Chylothorax, right, left, or bilateral, is a recognized complication of central venous cannulation,7 34 and stellate ganglion,61 and coeliac plexus blocks.20 This may result from direct damage to the thoracic duct or thrombosis of the superior vena cava, innominate, or subclavian veins.

The clinical presentation of a chylothorax may be delayed from the time of injury if the patient is not receiving enteral feeding or is receiving continuous gastric suction. The probability of chylothorax is increased if the effusion increases in size with resumption of enteral feeding. The diagnosis can be confirmed by demonstrating a typical chylous composition (Table 1).

The principles of management include: (i) pleural drainage with appropriate fluid and nutritional replacement; (ii) measures to reduce the production of chyle; (iii) treatment of the underlying cause; and (iv) obliteration of the pleural space or ligation of a demonstrated thoracic duct leak.18Conservative therapy is usually tried first for 2–3 weeks, after which surgical/radiological intervention is considered.

Decompression of the pleural space by continuous tube drainage relieves symptoms and accurately monitors chyle loss. Fibrin clots can block the chest drains. Occasionally multiple chest drains are required, if there are multiple loculations and re‐accumulation. Placement of a chest drain may be difficult in the presence of a flail segment in patients with multiple trauma. Ultrasound or CT guided insertion of chest drains is helpful in these situations.

Replacement of daily losses of fluid, calories, proteins and electrolytes is essential to avoid severe hypovolaemia, hypoalbuminaemia, and malnutrition. Continuous loss of lymphocytes leads to immunosuppression and an increased susceptibility to infections. Chyle has been re‐transfused into patients to prevent the loss of lymphocytes and proteins, but this procedure has inherent technical difficulties.44 Oral or enteral nutrition may increase lymph flow and therefore is not generally encouraged. Commercially available enteral feeds with a fat content less than 1 g litre–1, which are rich in medium chain triglycerides, may be suitable for some patients. Total parenteral nutrition at the outset is now considered to be the optimal approach in critically ill patients.

In isolated case reports, chylothorax has been successfully treated with octreotide,40 and etilefrine.23 The exact mechanism of the action of octreotide is not clear. Octreotide is used in patients with high output gastrointestinal fistulae because of its inhibitory effect on gastric and pancreatic secretion. If gastrointestinal volume and enzymes are reduced by octreotide, it may subsequently decrease chyle flow in the thoracic duct. Etilefrine23 is a sympathomimetic agent used in the management of postural hypotension. It is thought to cause smooth muscle contraction of the thoracic duct and may thereby reduce the leak.

There have been case reports in children where persistent thoracic duct leaks have been reduced by the application of very high intrathoracic pressures over a number of days.19Also, the reduction of venous hypertension, secondary to pulmonary arterial hypertension, by inhaled nitric oxide has been found to be helpful in such cases.41 51

It may take several weeks for a chylothorax to resolve. A high volume chyle output predicts failure of continuing conservative management. The decision to abandon conservative management is frequently difficult. However, an operative intervention is usually indicated if the average daily chyle loss exceeds 1500 ml in adults, or chyle drainage is unchanged after 2 weeks of conservative management.

The thoracic duct can be tied off surgically to prevent leakage of chyle into the body cavities.6 21 Interventions including videoassisted thoracoscopy, thoracotomy, or pleurectomy have to be individualized depending on the primary cause.56 It may be helpful to administer nasogastric olive oil or cream before surgery in order to increase chyle flow and help identify the site of the leak. Alternatively methylene blue, injected between the toes, helps outline the thoracic duct. Percutaneous transabdominal catheterization of the cisterna chyli or thoracic duct has been used to embolize chylous fistulae.11 21 27 Following such interventions, lymph is thought to return to the venous circulation via collateral channels.

Although the mortality from chylothorax is decreasing, significant morbidity continues as a result of lymphopenia, hypoalbuminaemia, malnutrition, and prolonged hospitalization. Prolonged central venous catheterization, total parenteral nutrition, multiple chest drain insertions, and additional surgical procedures contribute to the risk.

Chylous ascites

In chylous ascites, chyle accumulates in the peritoneal cavity. It results from an obstruction or leak in either the cisterna chyli or its large afferent lymphatics. It has a similar aetiology to chylothorax. Lymphomas account for more than half of the cases. Abdominal and retroperitoneal surgical procedures can damage the lymphatics. In postsurgical cases, the diagnosis is often delayed because the peritoneal fluid is initially serous until enteral feeding is reintroduced.35

The diagnosis of chylous ascites is based on the chemical content of the peritoneal fluid. Peritoneal fluid in this condition is very rich in proteins, usually 50% greater than that of plasma. Management of chylous ascites is similar to that of chylothorax. Repeated paracentesis is performed for patient comfort and to minimize the risk of development of the abdominal compartment syndrome.35 Persistent chylous ascites following several weeks of conservative treatment warrants a more aggressive approach including insertion of a peritoneovenous shunt, percutaneous embolization,27 or direct surgical repair of the cisterna chili.35

Chylopericardium

Chylopericardium is a rare disorder in which chyle accumulates in the pericardial cavity. It can be congenital or secondary to pericarditis, pancreatitis, cardiac or thoracic surgery, or malignancies. Chylopericardium is seen in children undergoing cardiac surgery with development of cardiac tamponade. The principles of management include: pericardial drainage, a low lipid diet, and surgery in persistent cases.

Conclusions

The lymphatic circulation is important in health and disease but its functions are poorly understood and often overlooked. Clinicians need to be aware of lymphatic disorders, which have direct relevance to anaesthesia and intensive care medicine. It is likely that future research will uncover other functions for the lymphatic circulation.

6 Ways to Boost Circulation for Detoxing and Immunity

The link between cleansing and circulation

You probably give a lot more thought to maintaining your weight than your circulation. But if you’re interested in preventing disease and cleansing your body of  toxins, pollutants, additives and chemicals, your circulatory system is your friend — and it needs your help to stay strong.

Imagine your circulatory system as a network of tubular highways reaching every part of your body. Now imagine a traffic jam on one of those highways, with massive delays, excess pollution and a high risk of accidents.

To keep your circulation moving right along, you need to know these basics about circulation and the most effective ways to keep yours pumping.

The two types of circulation

The circulatory system actually consists of two distinct systems that work in tandem: the cardiovascular circulatory system and the lymphatic circulatory system. Mia Harper, a licensed massage therapist at MediSpa at Mercy Hospital in Baltimore, explains how the two systems work together to detox the body.

“As nutrient-rich blood travels away from your heart, it progresses through smaller and smaller tubes, called capillaries,” she says. “In nearby tissue cells, nutrients and waste are exchanged. Fluid squeezed from the blood, called interstitial fluid or “lymph,” transports waste to your lymph nodes (via a series of vessels similar to veins) where the fluid is neutralized, filtered and eventually returned to the bloodstream.”

1. Cardiovascular circulation

Your heart is the power behind your cardiovascular circulatory system, pumping blood through your blood vessels, supplying every part of your body with the oxygen and nutrients it needs for proper functioning. With poor circulation, not only is your blood flow impaired, compromising that blood supply, but your heart is unduly taxed. Both have negative consequences and can lead to a variety of health problems.

“Poor circulation can lead directly to heart attack, stroke, eye disease, kidney disease, and claudication (leg muscle pain or weakness that comes and goes after an activity like walking),” says Dr. David Katz, Associate Professor in Public Health Practice at the Yale University School of Public Health and director of the Integrative Medicine Center in Derby, Conn. “But poor circulation also plays a role in almost every disease, from dementia to diabetes, influenza to cirrhosis.”

2. Lymphatic flow

Your lymphatic circulatory system works directly with your cardiovascular circulatory system to keep blood and lymphatic fluid levels in balance and flush toxins out of the body. It also carries immune cells throughout the body to help defend against infections.

But your lymphatic system isn’t lucky enough to have a powerful organ like the heart to keep fluid flowing. “The lymph system is stimulated by gravity, muscle contraction (exercise), hydrotherapy (alternating hot and cold water on the skin), breathing, lymph drainage therapy and massage,” says MediSpa’s Harper.

If your lymphatic circulation slows or stagnates, toxins will accumulate and immune cells won’t be delivered to the areas of the body where they’re needed, causing a variety of ailments, the very least of which are aches, pains and swelling (lymph edema). This can also cause deterioration of your thymus gland, tonsils and spleen – key components of your immune system — and weaken your body’s ability to fight infection and disease.

6 activities that boost both kinds of circulation

There are a number of easy and effective ways to improve the health of both your cardiovascular and lymphatic circulatory systems:

1. Drink plenty of water

“Circulation is vital to all of the body’s functions, and water makes up a large part of blood volume,” explains Katz. So make sure you drink enough water every day and don’t allow yourself to get dehydrated, causing undue taxation on your circulatory system.

But does water help flush toxins from your system? Katz explains that adequate hydration is required for adequate perfusion, which in turn is required for adequate function, detox included. “And water-soluble toxins go out with water, so adequate hydration is certainly directly relevant for kidney function.”

2. Exercise regularly (both cardio and strength training)

Any activity that contributes to overall fitness will also contribute to a strong circulatory system.

  • Regular aerobic activity is good for the health of your heart and blood vessels.
  • Resistance training adds to muscle mass, which increases the efficiency of both cardiovascular and lymph circulation, explains Katz.

3. Eat healthy

Circulation is yet another aspect of your health that benefits when you eat healthfully. “Lymph is made up of immune cells,” says Katz, “so the quality of lymph is enhanced by practices that boost immunity, including a healthy, balanced diet and weight control.“

4. Get a massage

By applying pressure to the body, massage stimulates the blood and lymph vessels, helping move the fluid along.

“Studies suggest that massage may enhance circulation in a localized manner to alleviate pain, reduce inflammation, and perhaps accelerate healing,” says Katz, “similar to the way that applying pressure to a tube squeezes out the toothpaste.”

5. Try manual lymph drainage therapy

By applying pressure in specific ways that target lymph nodes and vessels, a therapist trained in the lymphatic drainage therapy technique can directly target the lymph system to activate lymphatic fluid circulation and stimulate the functioning of the immune and parasympathetic nervous systems.

The technique includes holding the hands flat and moving them over the body to detect and assess current lymph flow patterns, and moving them in wave-like movements to release blockages in the network of lymph nodes and vessels.

“The benefits of lymph drainage therapy include a reduction of inflammatory responses (both acute and chronic), detoxification, regeneration of tissue, and deep relaxation, to name just a few,” says Harper.

The American Massage Therapist Association’s locator page can help you find a massage therapist trained in lymph drainage therapy techniques.

6. Shake it up with vibration and rebounding therapies

It seems obvious that shaking and bouncing your body around will get your blood pumping. But is there any evidence that they actually work to increase cardiovascular circulation and lymph flow? Turns out there is: A recent study published in Medical Science Monitor found that “Five minutes of 30 Hz or 50 Hz vibration produced significant increases in skin blood flow.”

Rebounding (jumping on a trampoline) appears to be especially effective at improving lymph system circulation. Lymphatic fluid is completely dependent on physical exercise to move, and the up-and-down rhythmic gravitational force caused by jumping on a trampoline causes the lymph system’s one-way valves to open and close, increasing lymph flow.

“The repetitive rhythmic motion of bouncing on a mini trampoline provides a simple, zero-impact exercise method with long-term mental and physical health benefits,” writes Dr. Tina Wellman, a psychoneuroendocrinologist and author of books on blending exercise, nutrition and detoxification to achieve wellness, in an article for Total Health. ”These benefits include increasing oxygen uptake and promoting detoxification via the lungs, skin, and lymph.”