Lymphedema Flashcards
What are the primary or central lymphatic organs?
thymus
bone marrow
What are the primary or central lymphatic organs?
thymus
bone marrow
What are the secondary of peripheral lymphatic organs?
- lymph nodes
- spleen
- Peyer’s patches in GIT
- tonsils
What are the functions of lymphatics?
- substance transport
- filtration
- lipid absorption
What are the substances carried from interstitial fluid through the lymphatics back to the circulation?
- water
- electrolytes
- polypeptides, cytokines, growth factors (low molecular-weight moieties)
- fibrinogen, albumin, globulins, coagulations & fibrinolytic factors (macromolecules)
What is the first-line of the immune system’s defense?
filtration of microbes in interstitial space by lymph nodes
Where does lipid absorption occur?
in Peyer’s patches in the bowel
An abnormal limb swelling caused by the accumulation of increased amounts pf high protein ISF secondary to defective lymphatic drainage in the presence of near normal net capillary filtration is the definition of?
lymphedema
what is the difference between edema & lymphedema?
EDEMA
- capillary filtration rate is pathologically high due to venous impairment so it overwhelms the normal lymphatic system
- resulting in accumulation of low-protein edema fluid
LYMPHEDEMA
- capillary filtration rate is normal & edema fluid is relatively high in protein
- primary problem is in the lymphatics
What is the end result of any edema?
- protein rich edema fluid
- increased deposition of ground substance
- subdermal fibrosis
- dermal thickening & proliferation
Where is lymphedema confined to?
epifascial space
in which type of edema will there be compensation?
- VENOUS INSUFFICIENCY can be compensated by increase in lymph flow (because lymphatic vessels can remove fluids)
- LYMPHATIC INSUFFICIENCY can’t be compensated because the venous system cannot reabsorb HMW proteins
What are the mechanisms of lymphedema?
- lymphatic aplasia or hypoplasia
- lymphatic dysmotility
- congenital lymphatic obliteration
What are the types & cause of PRIMARY lymphedema?
cause is congenital lymphatic dysplasia
LYMPHEDEMA CONGENITA
LYMPHEDEMA PRAECOX
LYMPHEDEMA TARDA
which type of primary lymphedema occurs after 35 years?
Lymphedema tarda
What type pf primary lymphedema occurs in patients aged <2 years?
lymphedema congenita
What type of lymphedema has an onset between 2-35 year old patients?
lymphedema praecox
what are the types of secondary lymphedema?
- traumatic
- post irradiation
- infective
- malignant (breast cancer)
- post-thrombotic
How is does traumatic lymphedema develop?
- POST OP: post-mastectomy lymphedema (never give saline in same side)
- KELOIDS: obstruct lymph return
- ACCIDENTAL: circumferential skin loss following extensive injury or burn
How does infective lymphedema develop?
- Bacterial infection
- Fungal infections (tinea pedis)
- Parasitic (filariasis): Elephantiasis Arabum
What is the initial presentation of lymphedema?
PAIN from heaviness & swelling
What is the clinical presentation of the early stages of lymphedema?
- usually involves the foot
- contour of ankle is lost through infilling of submalleolar depressions
- buffalo hump forms on dorsum of foot
- toes appear square due to confinement of footwear
- Stemmer’s sign (skin on dorsum of foot can’t be pinched due to subcutaneous fibrosis)
- pitting edema that pits less in the morning
REVERSIBLE STAGE
What are the late clinical manifestations in lymphedema?
- failure to control reversible stage -> fibrosis, dermal thickening, & hyperkeratosis
- chronic eczema & fissuring
- fungal infection of skin & nails (dermatophytosis & onychomycosis)
- verrucae & papillae (warts)
- lymphangiomas
- lymphangiosarcoma
dilated dermal lymphatics that blister onto skin were seen in a patient, the patient complained that they usually weep. What is your diagnosis & what is the sequele of this symptom?
LYMPHANGIOMA
weeping -> lymphorrhea, chylorrhea
will later thrombose & fibrose forming hard nodules
When does lymphangiosarcoma develop?
POST-MASTECTOMY EDEMA (Stewart-Treves’ syndrome) -> onset of 10 years
can develop in any longstanding lymphedema -> onset is longer than 20 years
What are the manifestations of lymphangiosarcoma?
- ulcerations
- non healing bruises
- single or multiple bluish/red skin & subcutaneous nodules that spread to form satellite lesions
How can you confirm a diagnosis of lymphangiosarcoma?
skin biopsy
What is the best chance of survival in regards to lymphangiosarcoma?
- amputation is the last option but it will offer less than 3 years
What investigations could confirm your diagnosis based on history & examination?
- lymphangiography
- isotope lymphoscintigraphy
- CT
- MRI
- ultrasound
- skin biopsy
What is the primary diagnostic technique in case of clinical uncertainty?
ISOTOPE LYMPHOSCINTIGRAPHY
- provides qualitative measure of lymphatic function
What method of investigation is used to exclude pelvic or abdominal mass lesions?
axial CT slice through midcalf
- course, non-enhancing, reticular HONEYCOMB pattern in enlarged subcutaneous compartment
What is the most important step in treatment of lymphedema?
PREVENTION of at-risk patients from onset of disease
What is the treatment strategy in case of lymphedema occurrence?
relieve pain
reduce swelling
prevent development of complications
What should pain be relieved?
- non opioid & opioid analgesic
- corticosteroids
- tricyclic antidepressants
- nerve blocks
- physiotherapy
REDUCE SWELLING & PREVENT COMPLICATIONS
How is swelling controlled?
DECONGESTIVE LYMPHEDEMA THERAPY 2 phases
1) short intensive period of therapist led:
- skin care
- manual lymphatic drainage
- multilayer lymphedema bandaging & compression garments (most common)
- exercises
2) maintenance phase: patient self-care with occasional professional intervention
What is the most common method of management?
compression garments
- requires higher pressures (30-40 in arm & 40-60 in leg)
- patient should put stockings first thing in the morning
What drugs could be given?
FLAVONOIDS
- reduce capillary permeability
- improve microcirculatory perfusion
- stimulte interstitial macrophage proteolysis
DIURETICS
- no value in pure lymphedema
What are the types of surgeries that could be performed in case of lymphedema?
BYPASS
- converting lymph to vein
LIMB REDUCTIONS PROCEDURES
- debulking
