lymphedema

Question 1

lymphatic system

Answer 1

• collection and transportion of fluids and other materials that are not reabsorbed by venous system, maintenance of fluid balance within body, immunse defense
• network of superficial and deep lymph vessels that transport lymph throughout body
• lymph vessels located anywhere blood supply exists - except brain and SC
• other components - thymus, bone marrow, spleen, tonsils, peyer patches in small intestine: production of lymphocytes for immune system

Question 1

lymph

Answer 1

• originates as component of interstitial fluid
• consists of water, proteins, fatty acids, cellular components

Question 2

flow of lymph

Answer 2

• initial vessels near blood capillaries - collect fluid from interstitium not picked up by venous systems
• intial vessels -> lymph collectors -> lymphatic trunks (R lymphatic duct - R arm and R side of head; thoracic duct - rest of body) -> venous system via subclavian veins

lymphatics transport most extracellular proteins - too large

Question 3

lymphatics collect _ % of interstitial fluid, while venous system collects other - %

Answer 3

lymphatics 10-20%
venous system 80-90%

Question 4

lymphatic system under control of

Answer 4

ANS - produces contractions of smooth muscles within lymph vessels to move lymph
- also moved by skeletal muscle contraction compressing lymph vessels
- one-way valves maintain unidirectional flow of lymph

Question 5

lymph nodes

Answer 5

• neck, axilla, chest, abdomen, groin
• collect lymph from adjacent areas
• function to filter wate products and foreign materals (bacteria, viruses) - provide immune system defense with use of T and B lymphocytes

Question 6

lymphedema

Answer 6

• chronic, incurable
• accumulation of protein-rich fluid (lymph) in body -> edema
• usually in extremities, face, neck, abdomen, genitalia, trunk
• fluid accumulation s/t daage to lymph structures
• primary or secondary

Question 7

primary lymphedema

Answer 7

• d/t abnormal development of lymphatic system from birth
• can take years to be symptomatic
• abnormalities can include absence of lymph vessels, decreased number/size of lymph vessels, increased size of lymph vessels -> incompetent valves
• more often in female, more often in LEs

Question 8

secondary lymphedema

Answer 8

• d/t some other disease or injury damaging LS
• trauma, surgery, radiation, tumor growth, multiparity, chornic venous insufficiency, infection
• in US, breast cancer surgery and treatment is most common cause

Question 9

3 types of insufficiencies in LS that lead to lymphedema

Answer 9

• dynamic: excess lymph circulating in LS that exceeds transport capacity of system; results in pitting edema -> chronic venous insufficiency, CHF, pregnancy
• mechanical: transport capacity of system reduced d/t to damage to LS; results in protein-rich, non-pitting lymphedema
• combined: both an increase in lymph and decrease in transport capacity

Question 10

diagnosis of lymphedema

Answer 10

• medical history, exam, imaging
• direct lymphography: injection of contrast medium into lymph vessel for visualization of entire lymph system through radiography; not common
• indirect lymphography: injection of water-soluble medium under skin to allow for visualization of smaller superficial lymph vessels
• lymphoscintigraphy: injection of radioactive material for visualization through nuclear medical imagaing, preferred over direct d/t fewer complications
• MRI and CT: ID tumors that may cause lymphedema

Question 11

most common method for measuring lymphedema

Answer 11

circumferential measurements

Question 12

circumferences for limb edema

Answer 12

• 7 circumferences recommended for UE and LE to deduce fluid has been removed and not just redistributed
• use opposite limb for comparison if able - differences of 2-3 cm between 4 circumferences on BUEs is lymphedema

Question 13

classification measurements for lymphedema

Answer 13

• mild: < 3 cm difference btw affected and unaffected limbs
• moderate: 3-5 cm difference btw affected and unaffected limbs
• severe: > 5 cm difference between affected and unaffected limbs

Question 14

other options to measure lymphedema

Answer 14

volumetric measurements
goniometry
MMT
pain assessment
sensory testing
skin inspection
bioelectrical impedance
gait and balance

Question 15

lymphedema staging

Answer 15

• 0: latent (preclinical) stage, no visible edema though capacity oflymph system has been affected
• 1: reversible stage, pitting present and increases with activity or heat but diminishes with elevation and rest
• 2: spontaneously irreversible stage; non-pitting, does not change wiht elevation or rest; fibrotic skin changes, risk of infection increases; Stemmer’s sign (+, cannot pinch skin)
• 3: lymphostatic elphantiasis stage, non-pitting, significant fibrotic changes, presence of papillomas, deep skinfolds, hyperkeratosis, infection, (+) stemmer’s

Question 16

lymphedema treatment - complete decongestive therapy

CDT

Answer 16

• manual lymphatic drainage (MLD): techniques to move lymph around blockages to draining areas, uninvolved areas first to prep then involved
• compression thearpy: maintains reduction in edema from MLD, short stretch bandages used - low resting pressure (do not constict lymph flow like long-stretch bandages), use different fitted garments at night, use graded compression for more pressure distally
• exercise: increase lymph vessel contraction, muscle pump to stimulate flow; trunk then extremity exercise w/ proximal to distal, deep breathing; should use compression bandages and garments when exercising
• skin care: more prone to damaged skin bc protein-rich fluid impairs immune system function - allows for bacterial and fungal growth; should prevent issues - inspect skin, moisturize

Question 17

other lymphedema treatments

Answer 17

• no meds or surgical procedures
• debulking - sx to remove excessive skin that forms in later stages of disease; can damage existing lymph vessels and further accelerate disease course
• intermittent pneumatic compression devices - some concern if pressure is too high might damage lymphatic vessle s

Question 18

contraindications of decongestive therapy

Answer 18

• acute infection
• cardiac edema
• DM
• HTN
• malignancy
• renal insufficiency
• DVT

Question 19

filariasis

Answer 19

• parasitic infection most often seen in tropical climates
• one of the most common causes of secondary lymphedema worldwide

Question 20

hyperkeratosis

Answer 20

thickening of outermost layer of skin, typical with stage 3 lymphedema

Question 21

lymphadenitis

Answer 21

• infeciton and inflammation of a lymph node
• acute or chronic

Question 22

milroy’s disease

Answer 22

• inherited type of primary lymphedema in infancy
• BLE edema most common s/s

Question 23

non-pitting edema

Answer 23

• harder fluid accumulation, not compressible when pressure applied
• in later stages of lymphedema

Question 24

papilloma

Answer 24

• benign wart-like skin growth typically observed w/ stage 3

Question 25

pitting edema

Answer 25

• fluid accumulation that can be compressed and indents with pressure
• early stages

Question 26

spleen

Answer 26

• organ in LUQ
• filters RBCs and produces antibodies to fight infection

Question 27

stemmer’s sign

Answer 27

• diagnosis of lymphedema
• (+) if skin at dorsal base of second toe/finger can’t be easily lifted away from bone - indicates thickening of skin d/t fibrotic changes

Question 28

thymus

Answer 28

• organ posterior to sternum and anterior to heart
• produces T cells and T lymphocytes to help combat infection