10.3 (11.3) Lymphedema

Question 1

List three factors that determine capillary filtration

Answer 1

• hydrostatic pressure gradient across capillary wall (pushes fluid out of capillary)
• colloid osmotic (oncotic) pressure due to plasma proteins which draw fluid in capillary wall
• permeability of capillary wall

Question 2

Flow along lymphatics is dependent on what three factors

Answer 2

◆ an intrinsic ‘pumping’ effect of smooth muscle and valves within the walls of larger lymph vessels

◆ extrinsic compression by skeletal muscle activity (similar to effect on venous flow)

◆ drainage into veins: fluid is re-absorbed from lymphatics into the veins within LNs, such that the flow of afferent lymph vessels into LN is > than efferent lymph vessels carrying lymph out of LN

Question 3

Edema can occur because of failure of lymphatic drainage.

List three mechanisms by which this happens

Answer 3

◆ mal-development of the lymphatics (primary lymphoedema)

◆ damage to the lymphatics from surgery, radiotherapy, infection, trauma, and cancer (secondary lymphoedema) TINS-R

◆ malfunction of the lymphatics due to reduced extrinsic compression by skeletal muscles in conditions resulting in immobility

Question 4

List FOUR causes of oedema in advanced cancer (relating to venous and lymph vessels)

Answer 4

◆ lymphatic damage due to treatment or malignant lymphadenopathy

◆ venous obstruction by tumour or by intrinsic obstruction by thrombosis or tumour

◆ lymphatic & venous malfunction due to immobility (dependency oedema)

◆ hypoalbuminemia

Question 5

List four causes of secondary lymphedema

Answer 5

◆ surgery
◆ radiation
◆ infection
◆ trauma
◆ neoplasm

FS: TINS - R

Question 6

Edema formation can occur by what three mechanisms and given an example of each

Answer 6

◆ Failure of lymphatic drainage
- mal-dev of lymphatics (primary)
- damage sec to sx, rads, infection, trauma, & cancer (secondary - TINS-R)
- malfunction due to reduced ext. compression by skeletal muscles due to immobility (ex. paraparesis)

◆ Increased venous pressure
- DVT
- chronic venous HTN sec to varicose veins
- heart failure
- chronic immobility (as above)

◆ hypoalbuminemia: inc cap filtration due to dec colloid oncotic pressure
- advanced cancer
- advanced liver disease
- nephrotic syndrome

Question 7

List four common skin changes that occur due to lymphedema

Answer 7

◆ Skin thickening*

◆ Hyperkeratosis: build-up of the horny layer of the skin

◆ Chronic inflammation: erythema of the skin and can be similar to the chronic lipodermatosclerosis seen in venous disease.*

◆ Lymphangiectasia: dilated lymph vessels which appear on the skin surface like small blisters, which if damaged can leak lymph (lymphorrhoea)*

◆ Papillomata: these skin lesions are similar to lymphangiectasia but also contain fibrous tissue, giving them a firmer consistency; (cobblestone-like appearance to the skin)*

◆ Increased skin creases

◆ Stemmer’s sign (usually positive):
- inability to pick up a fold of skin over the proximal phalanx second toe in lymphoedema of the leg
- In normal toes Stemmer’s sign is negative, that is, one can pick up a fold of skin at the toe base.

FS: thick, cobblestone, erythema, lymphangectasia

Question 8

List three words to describe the pain associated with lymphedema

Answer 8

ache, tightness, or heaviness

Question 9

List four general techniques for the management of lymphedema

Answer 9

massage

skin care

Compression

Exercise

Question 10

List three types of compression techniques for the management of lymphedema

Answer 10

Multilayer lymphoedema bandaging
Velcro compression wraps
Elastic compression garments
Intermittent pneumatic compression pumps

Question 11

List four contraindications to the use of compression for lymphedema

Answer 11

• acute cellulitis *
• severe heart failure*
• renal failure*
• around primary tumours, and metastases*
• hypertension
• ascites
• superior vena cava obstruction

WP: can’t find this info in 5th or 6th Ed.

Question 12

Manual lymphatic drainage is best used on what parts of the body (list 3)

Answer 12

• midline oedemas such as head/neck,
  trunk, breast, genital
• where there is swelling at the root of an edematous limb
• areas where it is difficult to create effective compression garments

Question 13

What is the role of each of the following medications in the management of lymphedema:

• furosemide
• antibiotics
• steroids

Answer 13

• furosemide - largely ineffective unless chf also present
• antibiotics - only if cellulitis also present
• steroids - Corticosteroids can sometimes be helpful in relieving lymphatic and extrinsic venous obstruction (IVC or SVC syndromes)

Question 14

What organism is most commonly implicated in cellulitis in the setting of lymphedema

Answer 14

beta haemolytic streptococci

Question 15

A patient presents with lymphedema what blood tests might you order and why?

Answer 15

CBC - to rule out anemia
Plasma proteins - hypoalbuminaemia
LFTs - liver disease
Cr/lytes - renal function
BNP - CHF

6th Ed. Table 10.3.1

Question 16

Name TWO imaging investigations for a patient w/ lymphedema and why?

Answer 16

◆ Ultrasound
- venous system: venous dz, incompetence, thrombosis
- abdo: intra-abdo dz
- axilla/breast: malig recurrence

◆ CT/MRI: extent of malig

6th Ed. Table 10.3.1

Question 17

Name TWO complications of lymphoedema and their treatments

Answer 17

◆ Cellulitis
- PO antibiotics at home
- local hospital antibiotic guidelines

◆ Lymphorrhoea: leakage of lymph fluid from edeamtous limb
- compression bandage w/ absorbant padding