Lymphatics & Lymphedema Flashcards
Stage 0 Lymphedema
- No visible changes but may have mild tingling, unusual tiredness, or slight heaviness
- reduced transport capacity
Stage 1 Lymphedema
- Mildly swollen arm, hand, trunk, breast or other
- Pitting edema
- reversible w/treatment
- swelling resolves w/elevation
- pt may CO heaviness, tightness, sensory changes, or pain in the limb
Stage 2 Lymphedema
- non-pitting edema that is not relieved by elevation
- changes to tissue under skin: inflammation, hardening, or thickening
- can be treated but is not reversible
- positive stemmer sign
- inc likelihood of skin infection
Stage 3 lymphedma
- most advanced stage (rare in breast cancer)
- large and misshapen limb w/leathery wrinkled appearance
- skin is fibrotic
- positive stemmer
- lack of pitting edema
List some OM that can be used for lymphedma
- Lymph- ICF
- Lymphoedema QOL Tools (LYMQOL arm/leg)
- Lymphedema Life Impact Scale (LLIS)
- SPADI
- DASH
What is the anatomy of the lymphatic system?
- spleen
- thymus
- tonsils
- peyer’s patches (in small intestine)
- bone marrow
- lymph nodes
What are peyer’s patches?
Located in the small intestine, they destroy bacteria and generate “memory lymphocytes” for long-term immunity
What are the superficial vessels of the lymphatic system responsible for?
- located directly under the skin and above the fascia, they drain the dermis and subcutaneous tissue
What are the deep vessels of the lymphatic system responsible for?
Located below the fascia they drain all the tissue deep to fascia
What is the lymphatic system composed of?
- lymph capillaries
- lymphatic pre-collectors
- collectors
- ducts
- trunks
What are initial lymphatics
The smallest diameter vessels that consist of a single layer of overlapping flat endothelial cells that with no valves (fluid can move in any direction) and become pre-collectors
- more permeable than vascular capillaries & absorb larger molecules of protein and fat
What are lymphatic pre-collectors?
- w/an overlapping endothelial anatomy allowing them to absorb interstitial fluid, they have a limited # of valves & some smooth mm structure that allows them to initiate transportation of the collected fluid
What are lymphatic collectors
- have 3 distinct layers and valves so that flow can only go towards the heart
- have lymphangions between the two valves
What is alymphangion?
A segment b/t two valves made up of innervated smooth muscle in lymph collectors that transports lymph fluid by distention, autonomic nervous system, and muscle pump/changes in total tissue pressure
What is a lymphatic watershed?
- describes the border where each area of lymph drains
What are the major watersheds of the body?
- midline of the body
- transect at the umbilicus
- divides head from torso
- down posterior surfaces of the limbs
How many lymph nodes do we have?
600-700 but it varies b/t individuals
Where are the major groups of lymph nodes?
armpits
groin
neck
abdomen
Functions of lymph nodes?
- help remove waste products & water from cells
- start immune response (biological filer stations)
Qualities of an acute infected lymph node
- tender to touch
- asymmetric
- enlarged
- matted together
- potential for redness of overlying skin
What are lymphatic trunks?
where superficial & deep collectors converge, they are similar to collectors except larger in diameter w/more smooth muscle
What are the lymphatic trunks (named)?
- Right and left lumbar trunks
- gastrointestinal trunk
- jugular trunk
- supraclavicular trunk
- subclavian trunk
- peristernal trunk
- bronchial-mediastinal trunk
What is cisterna chyli?
An enlarged lymphatic vessel (6 cm long) in the lumbar region (~L2) of the abdominal cavity that receives and temporarily stores lymph as it travels upward from the lower portion of the body
List the major lymphatic ducts
Thoracic Duct
Right lymphatic duct
What it the thoracic duct?
Where the bil LE, left side of trunk, L UE & left head and neck drains before emptying into the left internal jugular and subclavian veins
What is the right lymphatic duct?
drains the Right UE, right head neck and trunk into the right subclavian vein
What is lymphatic fluid composed of
water, proteins, macrophages, waste products (not CO2)
How many liters of lymph flow into the blood circulation daily?
2 L
How does starlings law of equilibrium work?
It describes how osmotic & hydrostatic pressures in the capillaries and interstitial tissue determine the direction of fluid movement - promoting filtration from the arterial end and reabsorption from the venous end of the capillaries to maintain homeostasis
Define lymphedma
chronic inflammatory condition that develops as a result of lymphatic insufficiency (from dec in reabsorption or dec in transport capacity in the venous syndrome)
Etiology of lymphedema
When lymphatics are unable to accommodate for and remove the protein rich fluid from the interstitial space causing fluid stagnation and edema
What is dynamic insufficiency?
Lymphatic system is unable to accommodate for and transport an increase in lymphatic load (above the normal lymph transport capacity)
What is mechanical insufficiency?
Lymphatic load may be normal but the lymphatic system is unable to transport this load (decreased functional reserve capacity)
What is the functional reserve capacity for lymph node system?
The difference b/t the normal lymph transport capacity and the normal lymph load
What is primary lymphedema?
congenital defect that can be present at birth or develop later on in a person’s lifetime
What is secondary lymphedema?
result of acquired damage (sx, radiation, trauma, tumor, CVI, or infection) to the lymph vessels or nodes and therefore impaired reabsorption and/or transportation of lymphatic fluid
What is the only clinical test that has been shown to be reliable and valid to dx lymphedema?
stemmer’s sign
What is stemmer’s sign
a thickening of the skin over the proximal phalanges of the toes/fingers of the involved limb and the ability to “tent” (pick up the skin)
Define lipedema
a metabolic dysfunction with bilateral/quadrilateral non-pitting soft edema but a lack of edema in the feet
typically is VERY painful
Lipedema vs Lymphedema
- symmetry
- swelling
- pain
- bleeding
- stemmers
- Lipedema = symmetrical, Lymph = asym
- Lipedema = no welling in foot w/characteristic ring at ankle, Lymph = swelling BEGINS at food
- Lipedema = extremely painful, lypmh - not painful, but heavy
- lipedema = bruising and subcutaneous bleeding, lymph - no
- lip = no stemmer, lymph = stemmer
List some common skin complications from lymphedema
- thickening
- subcutaneous fibrosis
- chronic inflammation
- ulceration
- papillomas
- warts
- skin flaps, folds, rolls
What are the two main complications from the failure of a primary lymphatic valve?
- fluid clx is less efficient = inc edema
- leaking initial lymphatics = accumulation of inflammatory mediators in tissue = increased inflammatory rxns
What happens in an acute inflammation?
the function of the initial lymphatics is compromised leading to increased edema due to decreased fluid clearance and increased inflammatory markers & therefore rxns in the tissue
What can occur in a secondary acute infection (lymphedema)
- cellulitis
- chronic fungal infections
- sepsis
What is lymphangitis
A serious, potentially life-threatening bacterial infection that spreads freely, quickly, and uncontrollably through the deeper tissues and the lymphatic or circulatory systems
What is fungal paronchia?
a fungal infection that affects the tissues surrounding a fingernail or toenail (secondary acute infection)
What functional mobility complications are seen due to lymphedema?
- dec ROM and strength
- gait deviations
- limitations in ADLs
What is lymphadenitis
An infection (usually strep or staph) of the lymph nodes when glands (usually near the site of underlying infection, tumor, or inflammation) become enlarged
What are the symptoms of lymphadenitis
- swollen, tender, or hard lymph nodes
- red, tender skin over lymph node
- may feel rubbery
What is lymphangitis
An infection (acute strep) of the lymph vessels causing an inflammation of the vessels and is sometimes confused w/a DVT
What are the symptoms of lymphangitis?
- red streaks from infected area to armpit/groin
- enlarged lymph nodes above red-streaks
- throbbing pain along affected area
- fever 100-104 deg F
- chills
- malaise
- HA
- loss of appetite
- mm aches
What should you do if you suspect lymphangitis?
send to ER
Risk factors for development of lymphedema?
- lymph node status
- radiation therapy
- sx complications
- time since sx
- increased BMI
- air travel w/o compression
- inflammation/inc lymphatic load
- dec lymphatic return
- individ prone to scar tissue formation
What are the current treatment options for lymphedema?
-
T or F: a low protein diet is advised w/lymphedema
False - there is no evidence that any diet plan helps
Diuretics & lymphedema
Diuretics are NOT effective bc it increases the concentration of proteins in the interstitial space exacerbating fibrosis rather than dec. the edema
What is lymphoscintigraphy?
A nuclear medicine imaging that provides pictures of the lymphatic system used to ID the sentinel lymph node, plan a biopsy/sx, and ID points of blockage in the lymphatic system
What types of imaging can be done for lymphedema?
- CT - shows honeycomb pattern of subcutaneous tissue
- dual energy x-ray (DEXA) - ST composition
- MRI- expensive
- US - skin thickness
What do you examine the integ system for w/lymphedema?
- texture
- color
- pitting
- fibrosis
- temp
- deepening of skin folds
- scars
- nail quality
- stemmer sign
- open wounds
- tissue mobility
- cyst, fistula, papilloma, and ulcer presence
Grade scale for pitting edema
1+ = trace, slight depression
2+ = mild, 0-0.6cm depression w/rebound <15 s
3+ = mod, 0.6-1.3cm, rebound 15-30 s
4+ = severe, 1.3-2.5 cm, rebound > 30 s
What is tonometry?
Measure of resistance of lymphedema tissues to compression by measuring “softness”
Why would you or would you not want to use water displacement to measure lymphedema?
- highly reliable & allows for measurement of irregular shaped objects
- hygiene concerns
What do you need to consider w/girth measurements and lymphedema?
- be consistent!!!!
- do not pull it tight
- high amount of user error, especially interrater reliability
What is optoelectric volumetry?
- use of infrared sensors to capture a 2D image of the limb w/volume calculated via a computer
- very outdated
What is a bioimpedance analysis
the use of electrical impedance of the current in the limb to estimate water content that MUST be done at the same time of day
- a lot of error as water content in the body is influenced by multiple factors
