Chap 65-67 Lymphedema Flashcards
What is the difference b/w high-input and low-output failure?
Give e.g. of each.
high-input
increased lymph prod > transport capacity even if lymph conduits normal. e.g. venous edema
low-output
pathologic condition compromises lymph flow
eg. hypoplasia/aplasia, abnormal valves
What is lymphedema?
various disease states characterized by the interstitial accumulation of protein-enriched fluid
What is the major classification of lymphedema?
Primary and secondary
What is a sub-clssification of primary?
congenital non-familial familial (milroy's) Praecox (age 1-35) non-familial familial (meige's disease) Tarda (age >35)
What is a sub-clssification of secondary?
filariasis lymph node excision tumor invasion infection trauma
What condition can congenital lymphedema be associated too?
turner, klingelters, trisomy 21, noonans
what is most common/rare form of primary?
praecox common tarda rare (10%)
what is most common secondary?
filariasis followed by breast cancer
20-30% of breast cancer patients
What is the morphological classification of lymphedema?
aplasia–absence of collecting vessels
hypoplasia–diminished number
numerical hyperplasia–increased number
hyperplasia–increased number and valve incompetence
What is most common parasite associated with filariasis lymphedema? How transmitted?
Wuchereria bancrofti (90%) mosquito and poor sanitation
How do you diagnose filariasis?
Eosinophilia found in periph blood smear, microfilaria in peripheral nocturnal blood, centrifuged urine sediment, lymphatic fluid
How do you stage lymphedema?
Latent phase: Excess fluid accumulates and fibrosis occurs around the lymphatics, but no edema is apparent clinically.
Grade I: Edema pits on pressure and is reduced largely or completely by elevation; there is no clinical evidence of fibrosis.
Grade II: Edema does not pit on pressure and is not reduced by elevation; moderate to severe fibrosis is evident on clinical examination.
Grade III: Edema is irreversible and develops from repeated inflammatory attacks, fibrosis, and sclerosis of the skin and subcutaneous tissue. This is the stage of lymphostatic elephantiasis.
What are associated skin chafes with lymphedema?
stemeners sign-square toes from edema
buffalo humb-dorsum of foot
feet may take woody texture
pinkish/red, warm
long-standing-thick, hyperkeratosis, peau d’orange
lymphorrhea–vesicles drain clear fluid
primary-yellow nail syndrome, clubbing and friability of nails
Is pain a symptom of lymphedema?
No. if painful suspect infection
what is most common complication of lymphedema?
why does it happen?
most common sources?
infection (31% of patients)
accumulation of fluid and protein god substrate for bacterial growth
lymph dysfunction impairs local immune responses
group A strep, staph species
What are other complications?
malnutrition from protein loss
immunodeficiency
Cancer
What are most common cancers associated with lymphedema?
lymphangiosarcoma (usually 2ary)
multicentric lesions with bluish nodules, sclerotic plaques or bullous changes
sarcoma
What modalities can you use to diagnose lymphedema?
Lymphoscintigraphy
CT/MRI
direct contrast lymphagiography
what is appearance of lymphedema on CT/MRI?
how is this different then venous edema and lipedema?
Lymphedema—honeycomb distributon of edema win epifascial structures, thickening of the skin
Venous edema, epi and subfascial compartements affected
Lipedema fat accumulation without fluid
What is differential diagnosis for lymphedema?
Systemic
Cardiac failure
Hepatic failure
Renal failure
Hypoproteinemia
Hyperthyroidism (myxedema)
Allergic disorders
Idiopathic cyclic edema
Hereditary angioedema
Drugs
Antihypertensives: methyldopa, nifedipine, hydralazine
Hormones: estrogen, progesterone
Anti-inflammatory drugs: phenylbutazone
Monoamine oxidase inhibitors
Local
Chronic venous insufficiency
Lipedema
–depostition of fatty tissue in subcu layers)
0besity
Congenital vascular malformation
(usually has larger limb, bruit
Arteriovenous fistula
Trauma
Snake or insect bite
Infection, inflammation
Hematoma
Dependency
Rheumatoid arthritis
Post-revascularization edema
Soft tissue tumor
Hemihypertrophy
Describe preventative treatments for lymphedema?
skin hygiene
clothing precautions
trauma avoidance
fungal/bacterial control
Describe non-surgical treatments for lymphedema?
limb elevation exercise diet pressure avoidance compression massage
What is ideal compression strength for lymphedema?
30-40mmHg or 40-50mmhg if really bad and chronic
How does subcutaneous fibrosis occur in lymphedema?
Insuff lymph transport leads to accumulation of hyaluronan and glycoproteins in extracellular space
Increase in fibroblast, keratinocytes, macs
Leads to increased collagen deposition and CT in skin and subcut
What abnormalities on lymphoscintigraphy are common for lymphedema?
Dermal backflow
Absent or delayed transport of tracer
Crossover filling with retrograde backflow
Absent or delayed visualization of lymph nodes
Obliterated channels
What are surgical techniques for lymphedema?
Lymph grafting
Lymphovenous anastomosis
Liposuction
