Primary Intestinal Lymphangiectasia: Difference between revisions

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==Overview==
==Overview==
Primary intestinal lymphangiectasia (Waldmann's disease) was first discovered by Waldmann T.A. in 1961 when he reported 18 cases of patients having edema with low serum albumin and gammaglobulin and proteins levels ''idiopathic hypercatabolic hypoproteinemia".'' PIL develops as a result of enlargement or dilatation of intestinal lymphatic vessels (lacteals) with leakage of their contents into the bowel lumen leading to hypoalbuminemia, hypogammaglobulinemia, and lymphopenia. The cause of PIL has not been identified. The prevalence of PIL is unknown. It can be asymptomatic. It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults. Symptoms include pitting edema, diarrhea, fatigue, abdominal discomfort, and malabsorption syndrome. PIL is diagnosed by biopsy revealing dilated intestinal lymphatics. Video-capsule endoscopy may be helpful when endoscopic findings are not conclusive. Common complications of PIL include infections, malignant transformation (lymphoma), and skin warts. There is no definitive treatment for PIL; the mainstay of therapy is a low-fat high protein diet with medium-chain triglyceride oral supplementation and supplemental calcium and vitamins. PIL is associated with significant morbidity and requires adherence to dietary modification and oral supplements; otherwise. it would be associated with poor outcomes and low quality of life. It can be fatal in some cases if anasarca or malignancy develops.
Primary [[intestinal]] lymphangiectasia ([[Waldmann disease|Waldmann's disease]]) was first discovered by Waldmann T.A. in 1961 when he reported 18 cases of patients having edema with low serum albumin and gammaglobulin and proteins levels ''idiopathic hypercatabolic hypoproteinemia".'' PIL develops as a result of enlargement or dilatation of intestinal lymphatic vessels (lacteals) with leakage of their contents into the bowel lumen leading to hypoalbuminemia, hypogammaglobulinemia, and lymphopenia. The cause of PIL has not been identified. The prevalence of PIL is unknown. It can be asymptomatic. It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults. Symptoms include pitting edema, diarrhea, fatigue, abdominal discomfort, and malabsorption syndrome. PIL is diagnosed by biopsy revealing dilated intestinal lymphatics. Video-capsule endoscopy may be helpful when endoscopic findings are not conclusive. Common complications of PIL include infections, malignant transformation (lymphoma), and skin warts. There is no definitive treatment for PIL; the mainstay of therapy is a low-fat high protein diet with medium-chain triglyceride oral supplementation and supplemental calcium and vitamins. PIL is associated with significant morbidity and requires adherence to dietary modification and oral supplements; otherwise. it would be associated with poor outcomes and low quality of life. It can be fatal in some cases if anasarca or malignancy develops.


==Historical Perspective==
==Historical Perspective==
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==Causes==
==Causes==
*The exact underlying [[Causes|cause]] of PIL has not yet been identified.
*The exact underlying [[Causes|cause]] of PIL has not yet been identified.
*[[Abnormal]] [[Gene expression|expression]] of the following several [[genes]] involved in the [[development]] of the [[lymphatic system]] is [[Association (statistics)|associated]] with PIL:<ref name="pmid18005011">{{cite journal| author=Hokari R, Kitagawa N, Watanabe C, Komoto S, Kurihara C, Okada Y | display-authors=etal| title=Changes in regulatory molecules for lymphangiogenesis in intestinal lymphangiectasia with enteric protein loss. | journal=J Gastroenterol Hepatol | year= 2008 | volume= 23 | issue= 7 Pt 2 | pages= e88-95 | pmid=18005011 | doi=10.1111/j.1440-1746.2007.05225.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18005011  }} </ref>
*[[Abnormal]] [[Gene expression|expression]] of the following several [[genes]] involved in the [[development]] of the [[lymphatic system]] is [[Association (statistics)|associated]] with PIL:<ref name="pmid18005011">{{cite journal| author=Hokari R, Kitagawa N, Watanabe C, Komoto S, Kurihara C, Okada Y | display-authors=etal| title=Changes in regulatory molecules for lymphangiogenesis in intestinal lymphangiectasia with enteric protein loss. | journal=J Gastroenterol Hepatol | year= 2008 | volume= 23 | issue= 7 Pt 2 | pages= e88-95 | pmid=18005011 | doi=10.1111/j.1440-1746.2007.05225.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18005011  }} </ref>
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==Differentiating PIL from other Diseases==
==Differentiating PIL from other Diseases==
*PIL must be differentiated from the secondary causes that lead to intestinal lymphangiectasia such as:
*PIL must be differentiated from the secondary causes that lead to intestinal lymphangiectasia such as:
**Intestinal [[tuberculosis]]
**Intestinal [[tuberculosis]]
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==Epidemiology and Demographics==
==Epidemiology and Demographics==
*The prevalence of PIL is unknown as it can be [[asymptomatic]].
*The prevalence of PIL is unknown as it can be [[asymptomatic]].
*It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults.<ref name="pmid50050">{{cite journal| author=Tift WL, Lloyd JK| title=Intestinal lymphangiectasia. Long-term results with MCT diet. | journal=Arch Dis Child | year= 1975 | volume= 50 | issue= 4 | pages= 269-76 | pmid=50050 | doi=10.1136/adc.50.4.269 | pmc=1544468 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=50050  }} </ref>
*It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults.<ref name="pmid50050">{{cite journal| author=Tift WL, Lloyd JK| title=Intestinal lymphangiectasia. Long-term results with MCT diet. | journal=Arch Dis Child | year= 1975 | volume= 50 | issue= 4 | pages= 269-76 | pmid=50050 | doi=10.1136/adc.50.4.269 | pmc=1544468 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=50050  }} </ref>
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===Age===
===Age===
*PIL is more commonly observed among children (less than 3 years old) and young adults.
*PIL is more commonly observed among children (less than 3 years old) and young adults.


===Race===
===Race===
*There is no racial predilection for PIL.
*There is no racial predilection for PIL.


==Risk Factors==
==Risk Factors==
*In 1964, Samman and White first described the yellow nail syndrome, a very rare condition that may be associated with PIL. This syndrome is associated with the following symptoms:<ref name="SammanWhite1964">{{cite journal|last1=Samman|first1=Peter D.|last2=White|first2=William F.|title=THE "YELLOW NAIL" SYNDROME.|journal=British Journal of Dermatology|volume=76|issue=4|year=1964|pages=153–157|issn=0007-0963|doi=10.1111/j.1365-2133.1964.tb14499.x}}</ref>
*In 1964, Samman and White first described the yellow nail syndrome, a very rare condition that may be associated with PIL. This syndrome is associated with the following symptoms:<ref name="SammanWhite1964">{{cite journal|last1=Samman|first1=Peter D.|last2=White|first2=William F.|title=THE "YELLOW NAIL" SYNDROME.|journal=British Journal of Dermatology|volume=76|issue=4|year=1964|pages=153–157|issn=0007-0963|doi=10.1111/j.1365-2133.1964.tb14499.x}}</ref>
**Dystrophic yellow nails
**Dystrophic yellow nails
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==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
*The majority of patients with PIL remain asymptomatic for years.
*The majority of patients with PIL remain asymptomatic for years.
*Early clinical features include edema of the lower limbs, diarrhea, and steatorrhea.
*Early clinical features include edema of the lower limbs, diarrhea, and steatorrhea.
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===Diagnostic Criteria===
===Diagnostic Criteria===
====Biopsy====
====Biopsy====
*PIL is diagnosed by biopsy revealing dilated intestinal lymphatics.
*PIL is diagnosed by biopsy revealing dilated intestinal lymphatics.


====Video-capsule endoscopy====
====Video-capsule endoscopy====
*Video-[[capsule endoscopy]] may be helpful when endoscopic findings are not conclusive.
*Video-[[capsule endoscopy]] may be helpful when endoscopic findings are not conclusive.


===History and Symptoms===
===History and Symptoms===
*The hallmark of PIL is [[pitting edema]] which usually affects lower limbs in moderate cases and face and external genitalia in severe cases. In some cases, it can extend to serous membranes causing [[pericardial effusion]], [[pleural effusion]], and [[chylous ascites]]. Rarely, it can cause [[anasarca]].
*The hallmark of PIL is [[pitting edema]] which usually affects lower limbs in moderate cases and face and external genitalia in severe cases. In some cases, it can extend to serous membranes causing [[pericardial effusion]], [[pleural effusion]], and [[chylous ascites]]. Rarely, it can cause [[anasarca]].
*Other symptoms include:
*Other symptoms include:
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===Laboratory Findings===
===Laboratory Findings===
*Low [[albumin]] level
*Low [[albumin]] level
*Low [[immunoglobulin]] IgM, IgA, and IgG levels
*Low [[immunoglobulin]] IgM, IgA, and IgG levels
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===Ultrasound===
===Ultrasound===
*Ultrasound may be helpful in the diagnosis of PIL.
*Ultrasound may be helpful in the diagnosis of PIL.
*Findings on ultrasound suggestive of PIL include:<ref name="pmid3511270">{{cite journal| author=Dorne HL, Jequier S| title=Sonography of intestinal lymphangiectasia. | journal=J Ultrasound Med | year= 1986 | volume= 5 | issue= 1 | pages= 13-6 | pmid=3511270 | doi=10.7863/jum.1986.5.1.13 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3511270  }} </ref>
*Findings on ultrasound suggestive of PIL include:<ref name="pmid3511270">{{cite journal| author=Dorne HL, Jequier S| title=Sonography of intestinal lymphangiectasia. | journal=J Ultrasound Med | year= 1986 | volume= 5 | issue= 1 | pages= 13-6 | pmid=3511270 | doi=10.7863/jum.1986.5.1.13 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3511270  }} </ref>
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===CT scan===
===CT scan===
*Abdominal CT scan with oral and intravenous [[contrast]] medium [[enhancement]] may be helpful in the diagnosis of PIL.
*Abdominal CT scan with oral and intravenous [[contrast]] medium [[enhancement]] may be helpful in the diagnosis of PIL.
*Findings on CT scan suggestive of PIL include:<ref name="pmid4019833">{{cite journal| author=Fakhri A, Fishman EK, Jones B, Kuhajda F, Siegelman SS| title=Primary intestinal lymphangiectasia: clinical and CT findings. | journal=J Comput Assist Tomogr | year= 1985 | volume= 9 | issue= 4 | pages= 767-70 | pmid=4019833 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4019833  }} </ref>
*Findings on CT scan suggestive of PIL include:<ref name="pmid4019833">{{cite journal| author=Fakhri A, Fishman EK, Jones B, Kuhajda F, Siegelman SS| title=Primary intestinal lymphangiectasia: clinical and CT findings. | journal=J Comput Assist Tomogr | year= 1985 | volume= 9 | issue= 4 | pages= 767-70 | pmid=4019833 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4019833  }} </ref>
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===Albumin scintigraphy===
===Albumin scintigraphy===
*99mTechnetium-labeled human serum albumin (99mTc-HSA) [[scintigraphy]] may reveal enhancement in the bowel, which indicates protein and lymph leakage into this part.
*99mTechnetium-labeled human serum albumin (99mTc-HSA) [[scintigraphy]] may reveal enhancement in the bowel, which indicates protein and lymph leakage into this part.


===Lymphangiography===
===Lymphangiography===
*[[Lymphangiography]] may be helpful in the diagnosis of PIL.
*[[Lymphangiography]] may be helpful in the diagnosis of PIL.
*Findings on lymphangiography suggestive of PIL include the abnormal dilation of the intestinal [[lymphatics]].
*Findings on lymphangiography suggestive of PIL include the abnormal dilation of the intestinal [[lymphatics]].
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==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
*There is no definitive treatment for PIL.
*There is no definitive treatment for PIL.
*The mainstay of therapy is a low-fat high protein diet with medium-chain [[triglyceride]] oral supplementation and supplemental calcium and [[vitamins]].
*The mainstay of therapy is a low-fat high protein diet with medium-chain [[triglyceride]] oral supplementation and supplemental calcium and [[vitamins]].
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===Surgery===
===Surgery===
*Segmental small bowel [[resection]] is only performed for localized lesions.<ref name="pmid14669360">{{cite journal| author=Chen CP, Chao Y, Li CP, Lo WC, Wu CW, Tsay SH | display-authors=etal| title=Surgical resection of duodenal lymphangiectasia: a case report. | journal=World J Gastroenterol | year= 2003 | volume= 9 | issue= 12 | pages= 2880-2 | pmid=14669360 | doi=10.3748/wjg.v9.i12.2880 | pmc=4612079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14669360  }}</ref>
*Segmental small bowel [[resection]] is only performed for localized lesions.<ref name="pmid14669360">{{cite journal| author=Chen CP, Chao Y, Li CP, Lo WC, Wu CW, Tsay SH | display-authors=etal| title=Surgical resection of duodenal lymphangiectasia: a case report. | journal=World J Gastroenterol | year= 2003 | volume= 9 | issue= 12 | pages= 2880-2 | pmid=14669360 | doi=10.3748/wjg.v9.i12.2880 | pmc=4612079 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14669360  }}</ref>


===Prevention===
===Prevention===
*There are no primary preventive measures available for PIL.
*There are no primary preventive measures available for PIL.



Revision as of 01:03, 23 January 2021

Primary Intestinal Lymphangiectasia Microchapters

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating PIL from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Mohamed Riad, M.D.[3]

Synonyms and keywords: PIL

Overview

Primary intestinal lymphangiectasia (Waldmann's disease) was first discovered by Waldmann T.A. in 1961 when he reported 18 cases of patients having edema with low serum albumin and gammaglobulin and proteins levels idiopathic hypercatabolic hypoproteinemia". PIL develops as a result of enlargement or dilatation of intestinal lymphatic vessels (lacteals) with leakage of their contents into the bowel lumen leading to hypoalbuminemia, hypogammaglobulinemia, and lymphopenia. The cause of PIL has not been identified. The prevalence of PIL is unknown. It can be asymptomatic. It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults. Symptoms include pitting edema, diarrhea, fatigue, abdominal discomfort, and malabsorption syndrome. PIL is diagnosed by biopsy revealing dilated intestinal lymphatics. Video-capsule endoscopy may be helpful when endoscopic findings are not conclusive. Common complications of PIL include infections, malignant transformation (lymphoma), and skin warts. There is no definitive treatment for PIL; the mainstay of therapy is a low-fat high protein diet with medium-chain triglyceride oral supplementation and supplemental calcium and vitamins. PIL is associated with significant morbidity and requires adherence to dietary modification and oral supplements; otherwise. it would be associated with poor outcomes and low quality of life. It can be fatal in some cases if anasarca or malignancy develops.

Historical Perspective

  • In 1961, primary intestinal lymphangiectasia (Waldmann's disease) was first discovered by Waldmann T.A., who reported 18 cases of patients having edema with low serum albumin and gammaglobulin and proteins levels ''idiopathic hypercatabolic hypoproteinemia". Assessment using radio-labeled 131I-albumin resulted in low levels in those patients. In addition, small intestinal biopsies were examined under a microscope revealing different degrees of lymphatic vessel dilatation.[1][2]
  • In 1964, Samman and White first described the yellow nail syndrome, a very rare condition that may be associated with PIL. This syndrome is associated with the following symptoms:[3]

Pathophysiology

Pathology

Genetics

Associated conditions

Gross pathology

Microscopic Pathology

Causes

Differentiating PIL from other Diseases

Disease Clinical manifestations Diagnostic studies
Intestinal Tuberculosis[6]
  • Fever
  • Night sweats
  • Abdominal pain
  • Weight loss
  • Anemia
  • Patients can present with obstructive symptoms
  • Pain in right iliac fossa (RIF)
  • Palpable mass in the right iliac fossa
Inflammatory bowel disease[7]
Intestinal lymphoma[8]
  • Biopsy
Constrictive pericarditis[9]
Sarcoidosis[10]
Systemic sclerosis[11]
  • Presence of autoantibodies (specifically anti-centromere and anti-scl70/anti-topoisomerase antibodies)
  • Biopsy (occasionally)
Whipple disease[12]
Radiation and/or chemotherapy with retroperitoneal fibrosis[13]
  • Flank pain
  • Abdominal pain
  • Unilateral or bilateral lower extremity swelling
  • Unexplained systemic symptoms such as:
    • Fatigue
    • Weight loss
  • Biopsy  showing fibro-inflammatory tissue without malignancy
HIV-related enteropathy[14]
  • Biopsy; however the diagnosis is challenging
Menetrier's disease
Inflammatory states of systemic lupus erythematosus

Epidemiology and Demographics

  • The prevalence of PIL is unknown as it can be asymptomatic.
  • It primarily affects children (generally diagnosed before the age of 3) and young adults but may be diagnosed later in adults.[15]
  • There are rare familial forms that have been reported.

Age

  • PIL is more commonly observed among children (less than 3 years old) and young adults.

Race

  • There is no racial predilection for PIL.

Risk Factors

  • In 1964, Samman and White first described the yellow nail syndrome, a very rare condition that may be associated with PIL. This syndrome is associated with the following symptoms:[3]
    • Dystrophic yellow nails
    • Nail ridging
    • Loss of lunula on the hands
    • Lymphedema
    • Pleural effusions
  • Other five syndromes considered as risk factors and associated with intestinal lymphangiectasia include:[5]

Natural History, Complications and Prognosis

  • The majority of patients with PIL remain asymptomatic for years.
  • Early clinical features include edema of the lower limbs, diarrhea, and steatorrhea.
  • If left untreated, patients with PIL may progress to develop edema of the external genitalia, edema of serous membranes, and life-threatening anasarca.
  • Common complications of PIL include:
  • A very rare complication is the gelatinous transformation of bone marrow in which hematopoietic cells and adipocytes are replaced by amorphous extracellular material composed of acid mucopolysaccharides.[23]
  • PIL is associated with significant morbidity and requires adherence to dietary modification and oral supplements; otherwise. it would be associated with poor outcomes and low quality of life. It can be fatal in some cases if anasarca or malignancy develops.

Diagnosis

Diagnostic Criteria

Biopsy

  • PIL is diagnosed by biopsy revealing dilated intestinal lymphatics.

Video-capsule endoscopy

History and Symptoms

A 23-year-old woman with PIL since infancy. Note the bilateral lower limb lymphedema, with accentuation of the dorsal flexion folds of the toes. [1]

Laboratory Findings

  • Low albumin level
  • Low immunoglobulin IgM, IgA, and IgG levels
  • CBC shows lymphopenia
  • Elevated 24-hour α1-antitrypsin clearance in stool, which is an indication of the degree of protein loss and disease severity Contrast lymphangiography

Ultrasound

  • Ultrasound may be helpful in the diagnosis of PIL.
  • Findings on ultrasound suggestive of PIL include:[32]
    • Dilation of the intestinal loops
    • Diffuse regular thickening of the intestinal wall
    • Mesenteric edema
    • Ascites (sometimes)

CT scan

  • Abdominal CT scan with oral and intravenous contrast medium enhancement may be helpful in the diagnosis of PIL.
  • Findings on CT scan suggestive of PIL include:[33]
    • Diffuse thickening of the small intestinal wall and edema
    • "Halo sign" (in some cases)
  • CT scan can also detect the localized lesions.

Albumin scintigraphy

  • 99mTechnetium-labeled human serum albumin (99mTc-HSA) scintigraphy may reveal enhancement in the bowel, which indicates protein and lymph leakage into this part.

Lymphangiography

  • Lymphangiography may be helpful in the diagnosis of PIL.
  • Findings on lymphangiography suggestive of PIL include the abnormal dilation of the intestinal lymphatics.

Treatment

Medical Therapy

  • There is no definitive treatment for PIL.
  • The mainstay of therapy is a low-fat high protein diet with medium-chain triglyceride oral supplementation and supplemental calcium and vitamins.
  • Other reported therapeutic options include:
    • Tranexamic acid (used to increase immunoglobulins and lymphocyte count)[34]
    • Steroids[35]
    • Octreotide[36]
    • Albumin infusion
      • It is a symptomatic treatment to improve hypoalbuminemia and edema but its effect is transient due to continuous lymph leakage into the bowel lumen.

Surgery

  • Segmental small bowel resection is only performed for localized lesions.[37]

Prevention

  • There are no primary preventive measures available for PIL.

References

  1. Vignes S, Bellanger J (2008). "Primary intestinal lymphangiectasia (Waldmann's disease)". Orphanet J Rare Dis. 3: 5. doi:10.1186/1750-1172-3-5. PMC 2288596. PMID 18294365.
  2. WALDMANN TA, STEINFELD JL, DUTCHER TF, DAVIDSON JD, GORDON RS (1961). "The role of the gastrointestinal system in "idiopathic hypoproteinemia"". Gastroenterology. 41: 197–207. PMID 13782654.
  3. 3.0 3.1 Samman, Peter D.; White, William F. (1964). "THE "YELLOW NAIL" SYNDROME". British Journal of Dermatology. 76 (4): 153–157. doi:10.1111/j.1365-2133.1964.tb14499.x. ISSN 0007-0963.
  4. 4.0 4.1 Hokari R, Kitagawa N, Watanabe C, Komoto S, Kurihara C, Okada Y; et al. (2008). "Changes in regulatory molecules for lymphangiogenesis in intestinal lymphangiectasia with enteric protein loss". J Gastroenterol Hepatol. 23 (7 Pt 2): e88–95. doi:10.1111/j.1440-1746.2007.05225.x. PMID 18005011.
  5. 5.0 5.1 Hennekam RC, Geerdink RA, Hamel BC, Hennekam FA, Kraus P, Rammeloo JA; et al. (1989). "Autosomal recessive intestinal lymphangiectasia and lymphedema, with facial anomalies and mental retardation". Am J Med Genet. 34 (4): 593–600. doi:10.1002/ajmg.1320340429. PMID 2624276.
  6. Ploddi A, Atisook K, Hargrove NS (1988). "Intestinal lymphangiectasia in intraabdominal tuberculosis". J Med Assoc Thai. 71 (9): 518–23. PMID 3249186.
  7. STEINFELD JL, DAVIDSON JD, GORDON RS, GREENE FE (1960). "The mechanism of hypoproteinemia in patients with regional enteritis and ulcerative colitis". Am J Med. 29: 405–15. doi:10.1016/0002-9343(60)90036-x. PMID 13834226.
  8. SUM PT, HOFFMAN MM, WEBSTER DR (1964). "PROTEIN-LOSING GASTROENTEROPATHY IN PATIENTS WITH GASTROINTESTINAL CANCER". Can J Surg. 7: 1–5. PMID 14103417.
  9. Wilkinson P, Pinto B, Senior JR (1965). "Reversible protein-losing enteropathy with intestinal lymphangiectasia secondary to chronic constrictive pericarditis". N Engl J Med. 273 (22): 1178–81. doi:10.1056/NEJM196511252732202. PMID 5847556.
  10. Popović OS, Brkić S, Bojić P, Kenić V, Jojić N, Djurić V; et al. (1980). "Sarcoidosis and protein losing enteropathy". Gastroenterology. 78 (1): 119–25. PMID 7350018.
  11. van Tilburg AJ, van Blankenstein M, Verschoor L (1988). "Intestinal lymphangiectasia in systemic sclerosis". Am J Gastroenterol. 83 (12): 1418–9. PMID 3195550.
  12. Laster L, Waldmann TA, Fenster LF, Singleton JW (1966). "Albumin metabolism in patients with Whipple's disease". J Clin Invest. 45 (5): 637–44. doi:10.1172/JCI105379. PMC 292741. PMID 4160668.
  13. Rao SS, Dundas S, Holdsworth CD (1987). "Intestinal lymphangiectasia secondary to radiotherapy and chemotherapy". Dig Dis Sci. 32 (8): 939–42. doi:10.1007/BF01296718. PMID 3608736.
  14. Stockmann M, Fromm M, Schmitz H, Schmidt W, Riecken EO, Schulzke JD (1998). "Duodenal biopsies of HIV-infected patients with diarrhoea exhibit epithelial barrier defects but no active secretion". AIDS. 12 (1): 43–51. doi:10.1097/00002030-199801000-00006. PMID 9456254.
  15. Tift WL, Lloyd JK (1975). "Intestinal lymphangiectasia. Long-term results with MCT diet". Arch Dis Child. 50 (4): 269–76. doi:10.1136/adc.50.4.269. PMC 1544468. PMID 50050.
  16. Hallevy C, Sperber AD, Almog Y (2003). "Group G streptococcal empyema complicating primary intestinal lymphangiectasia". J Clin Gastroenterol. 37 (3): 270. doi:10.1097/00004836-200309000-00015. PMID 12960729.
  17. Jabeen SA, Murthy A, Kandadai RM, Meena AK, Borgohain R, Uppin MS (2012). "Cryptoccocal menigitis as a primary manifestation in a patient with intestinal lymphangictasia". Ann Indian Acad Neurol. 15 (3): 218–20. doi:10.4103/0972-2327.99725. PMC 3424804. PMID 22919199.
  18. 18.0 18.1 Ward M, Le Roux A, Small WP, Sircus W (1977). "Malignant lymphoma and extensive viral wart formation in a patient with intestinal lymphangiectasia and lymphocyte depletion". Postgrad Med J. 53 (626): 753–7. doi:10.1136/pgmj.53.626.753. PMC 2496800. PMID 604991.
  19. 19.0 19.1 Gumà J, Rubió J, Masip C, Alvaro T, Borràs JL (1998). "Aggressive bowel lymphoma in a patient with intestinal lymphangiectasia and widespread viral warts". Ann Oncol. 9 (12): 1355–6. doi:10.1023/a:1008496900822. PMID 9932170.
  20. Bouhnik Y, Etienney I, Nemeth J, Thevenot T, Lavergne-Slove A, Matuchansky C (2000). "Very late onset small intestinal B cell lymphoma associated with primary intestinal lymphangiectasia and diffuse cutaneous warts". Gut. 47 (2): 296–300. doi:10.1136/gut.47.2.296. PMC 1728014. PMID 10896925.
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