Synonym/Acronym
Lymphangiogram.
Rationale
To visualize and assess the lymphatic system related to diagnosis of lymphomas such as Hodgkin disease.
Patient Preparation
There are no food, fluid, or activity restrictions unless by medical direction.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities. Sedatives or antihistamines may be ordered for the patient prior to the procedure to facilitate relaxation and cooperation.
Normal Findings
- Normal lymphatic vessels and nodes that fill completely with contrast medium on the initial films. On 24-hr images, the lymph nodes are fully opacified and well circumscribed. The lymphatic channels are emptied a few hours after injection of the contrast medium.
Study type: X-ray, contrast/special; related body system: Immune system.
Lymphangiography involves visualization of the lymphatic system after the injection of an iodinated oil–based contrast medium into a lymphatic vessel in the hand or foot. The lymphatic system collects and filters lymph fluid, moving the fluid in one direction from the surrounding tissues to the neck where it reenters the circulatory system. The lymphatic system consists of lymph vessels, lymph ducts, lymph nodes, tonsils, adenoids, spleen, and thymus. Lymph is a colorless to white fluid composed of lymphocytes (white blood cells produced by the bone marrow and thymus), excess plasma proteins, and chyle (emulsified fats) from the intestines. The filtration units of the lymphatic system are the lymph nodes and organs located in different parts of the body, such as the neck, armpit, groin, chest, and abdomen.
The main function of the lymphatic system is to provide immunological defense for the body against injury from disease or toxic chemicals. Assessment of this system is important because cancer (e.g., lymphoma and Hodgkin disease) often spreads via the lymphatic system. Painful edema of the extremities usually occurs when the flow of lymphatic fluid becomes obstructed by infection, injury, or cancer. Lymphangiography is performed for evaluating edema of unknown cause in an extremity; identifying lymph node involvement, which may indicate metastases from a primary tumor; staging cancer in patients with an established diagnosis of lymphoma or metastatic tumor to assist in monitoring progression of the disease; planning surgical intervention; and monitoring the effectiveness of therapeutic modalities such as chemotherapy or radiation treatment. Injection into the hand allows visualization of the axillary and supraclavicular nodes. Injection into the foot allows visualization of the lymphatics of the leg, inguinal and iliac regions, and retroperitoneum up to the thoracic duct. Less commonly, injection into the foot can be used to visualize the cervical region (retroauricular area).
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.
Patients with severe chronic lung disease, cardiac disease, or advanced liver disease.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Inability to cannulate the lymphatic vessels.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the lymphatic system.
- Advise the procedure takes 1 to 3 hr and is performed in the radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that contrast medium will be injected, by needle, catheter, or cannula, at a separate site from the IV line.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain the importance of remaining still during the procedure.
- Discuss how it will be necessary to return the next day for an additional set of images that will take about 30 min.
Procedural Information
- Advise that baseline vital signs will be recorded and monitored throughout the procedure.
- Positioning for this study is in a supine position on an x-ray table.
- The selected area is cleansed and covered with a sterile drape.
- A local anesthetic is injected at the site, and a small incision is made or a needle inserted.
- A blue dye is injected intradermally into the area between the toes or fingers.
- Lymphatic vessels are identified as the dye moves.
- A local anesthetic is then injected into the dorsum of each foot or hand, and a small incision is made and cannulated for injection of the contrast medium.
- The contrast medium is then injected, and the flow of the contrast medium is followed by fluoroscopy or images.
- The infusion of contrast medium is discontinued when the contrast medium reaches the upper lumbar level.
- X-ray images are taken of the chest, abdomen, and pelvis to determine the extent of filling of the lymphatic vessels.
- Delayed images are taken at 24 hr to examine the lymphatic nodes and to monitor the progress of delayed flow.
- Continuous monitoring is performed to assess for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
- Explain that once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.
- Alternately, the cannula is removed, the incision is sutured and bandaged.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Advise immediately reporting symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting.
- Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Instruct the patient to maintain bedrest up to 24 hr to reduce extremity swelling after the procedure or as ordered.
- Explain the care and assessment of the site and how to apply cold compresses to the puncture site as needed to reduce discomfort or edema.
- Explain that the skin, urine, and stool may retain a bluish hue from the dye for 2 to 3 days after the procedure until the dye clears from the body.
Clinical Judgement
- Consider how to address concerns regarding side effects of therapeutic treatment associated with Hodgkin disease.
Follow-Up and Desired Outcomes
- Acknowledges additional testing may be needed to monitor disease progression and evaluate the need for change in therapy.
- Agrees to attend grief counseling sessions related to prognosis of a specific diagnosis.