Lymphatic

Question 1

Primary lymphedema

Answer 1

Occurs due to abnormal development of the lymphatic system. May include absent lymph vessels, decrease in number or size of vessels, or increased size of lymph vessel, which makes valves incompetent.
Usually occurs in females and seen in LEs.

Question 2

Secondary lymphedema

Answer 2

Occurs as a result of some other disease or injury. May include trauma, surgery, radiation, tumor growth, multiparity, chronic venous insufficiency or infection.
In the US, most common cause is breast cancer surgery and treatment.

Question 3

Dynamic insufficiency

Answer 3

Most common type of insufficiency that leads to lymphedema.
Occurs when there is excess lymph circulating in lymph system.
Results in pitting edema
Associated with venous insufficiency, CHF, and pregnancy.

Question 4

Mechanical insufficiency

Answer 4

Occurs when transport capacity of system is reduced. Results in more protein rich lymphedema (non-pitting).

Question 5

Combined insufficiency

Answer 5

Occurs when there is both an increase in lymph fluid and a decrease in transport capacity.

Question 6

Lymphedema symptoms

Answer 6

Achiness, fullness, and heaviness of affected limb.
In later stages, proteins can degrade, which leads to the development of chronic inflammation and fibrotic changes to surrounding tissues.
Fibrosis leads to local hypoxia, which further causes chronic inflammation and increased risk for infection.

Question 7

Lymphedema prevention

Answer 7

Avoid injury to skin to reduce infection.
Avoid constriction, of extremity, like tight clothing or BP cuff
Diet and exercise to decrease being overweight
Observe size of limb during exercise and take frequent rest breaks with intense activity.
Avoid extreme hot and cold temperature because they can lead to fluctuations in limb edema
Wear compression garments during periods of strenuous activity, when standing for prolonged periods or when traveling on airplane.

Question 8

Imaging technique - Direct lymphography

Answer 8

Injection of contrast medium into a lymph vessel that allows for visualization of the entire lymph system through radiography. Not commonly used.

Question 9

Imaging technique -Indirect lymphography

Answer 9

Injection of a contrast medium (water soluble) just under the skin to allow for visualization of the smaller superficial lymph vessels

Question 10

Imaging technique - Lymphoscintigraphy

Answer 10

Injection of a radioactive material that allows for visualization of the lymphatic system through nuclear medical imaging. Traced throughout system to determine how effectively lymph is being transported. Fewer complications than direct lymphography

Question 11

Imaging technique - MRI and CT Scan

Answer 11

Can identify tumors that may be causing lymphedema

Question 12

Circumferential Limb Measurement

Answer 12

7 circumferences are recommended for UE and LE to deduce that fluid has been removed and not just redistributed.

Opposite limb used for comparison if available. A difference of 2-3 cm between 4 comparative circumferences on bilat UEs is evidence of edema.

Classifications:
Mild - < 3 cm difference between affected and unaffected limb
Moderate - 3-5 cm difference
Severe - > 5 cm difference

Question 13

Complete Decongestive Therapy

Answer 13

Treatment model that occurs in 2 different phases.
Phase I is intensive acute treatment phase that is typically provided on an outpatient basis for 4-6 weeks.
Phase II is the self-management phase consisting of long-term management of symptoms.
May need to return to phase I of treatment with a significant change in symptoms.

Question 14

Complete Decongestive Therapy - Manual Lymphatic Drainage

Answer 14

Techniques designed to move lymph around blockages in the lymph system and into desired areas where it can be drained.
Treatment should first be directed at uninvolved areas to prepare for new lymph flow from involved areas.
Important to know location of lymph nodes and if they are functioning.

Question 15

Complete Decongestive Therapy - Compression Therapy

Answer 15

Helps maintain reduction in edema achieved with MLD. Improves reabsorption ability of the capillaries and reduces filtration of fluid into interstitium. Can also help soften fibrotic tissues.

In phase I of treatment, bandages typically used. Short-stretch bandages used because they have a low resting pressure and therefore do not constrict lymph flow.

In phase II of treatment, a combination of compression garments (during the day) and compression bandages (during the night) are used. Compression garments should only be fitted once edema has plateaued. Bandages and garments should have higher pressure in distal regions (graded compression)

Question 16

Complete Decongestive Therapy - Exercise

Answer 16

Can help improve lymph flow by increasing lymph vessel contractions, increasing fluid uptake in the initial lymph vessels, improving “muscle pump” to stimulate lymph flow, and increasing deep breathing (which improves lymph flow in thoracic duct).

Program should be gradually progressed b/c can have a negative response to exercise. Low impact, aerobic activities recommended.

Start with trunk exercises, working towards proximal joints to distal joints of extremities. Finish with additional trunk exercises and deep breathing to enhance lymphatic flow.

Compression bandages/garments should be used when exercising.

Question 17

Complete Decongestive Therapy - Skin Care

Answer 17

Lymphedema impairs immune function, making skin more susceptible to bacterial and fungal growth and infections.

Limbs should be inspected and cleansed thoroughly each day. Lotion should be used often. Soaps and lotions should have low or neutral pH to avoid skin damage.

Question 18

Contraindications to Complete Decongestive Therapy

Answer 18

Acute infection
Cardiac edema
Diabetes
Hypertension
Malignancy
Renal insufficiency
DVT

Question 19

Debulking

Answer 19

Surgery to remove excessive skin that forms in later stages of lymphedema

Question 20

Stage 0 of Lymphedema

Answer 20

Latent or preclinical stage. No visible edema, though the transport capacity of the lymph system has been affected.

Question 21

Stage 1 of Lymphedema

Answer 21

Reversible stage. Pitting edema present and increases with activity or heat but will diminish with elevation and rest.

Question 22

Stage 2 of Lymphedema

Answer 22

Spontaneously irreversible stage. Edema is non-pitting and does not change with elevation or rest. Skin begins to demonstrate fibrotic changes and risk for infection increases. Stemmer’s sign is positive (thickened fold of skin at the base of the second toe or second finger that can be gently pinched and lifted, which indicates thickening of skin due to fibrotic changes).

Question 23

Stage 3 of Lymphedema

Answer 23

Known as lymphostatic elephantiasis stage. Extensive non-pitting edema, significant fibrotic changes to the skin, and presence of papillomas, deep skinfolds, and hyperkeratosis. Infection is common. Stemmer’s sign is positive.

Question 24

Filariasis

Answer 24

Disease caused by parasitic infection. Most common causes of secondary lymphedema worldwide.

Question 25

Lyphadenitis

Answer 25

Infection and inflammation of a lymph node, which can be acute or chronic.

Question 26

Lymphadenomegaly

Answer 26

Enlargement of lymph nodes, often secondary to cancer, infection, and allergic reaction.

Question 27

Lymphangitis

Answer 27

Infection and inflammation of the lymphatic system pathways

Question 28

Milroy’s disease

Answer 28

Inherited primary lymphedema that typically presents in infancy. Bilat LE edema is most common symptom.