Lymphedema

Front 1

what is lymphedema

Back 1

-swelling of tissue with protein rich fluid from disruption of lymphatic flow

Front 2

there are 2 types of lymphedema, primary and secondary; describe each

Back 2

-primary (from a congenital defect; aplastic, hypoplastc or hyperplastic lymphatics)
-secondary (from extrinsic damage)

Front 3

list some causes of secondary lymphedema

Back 3

-MC is cancer/tumor or radiation therapy for cancer tx
-venous insufficiency
-recurrent infection
-trauma

Front 4

Milroys disease

Back 4

-congenital form of lymphedema (primary lympedema) noted at birth
-firm, pitting, chronic, permanent lymphedema contained to the LE
-caused from aplastic lymphatics

Front 5

Lymph drainage system paralells the venous drainage systems adn moves lymph in one direction to return what, and to where

Back 5

-returns protein, colloids and particulate mater to systemic venous circulation

Front 6

how does lymph flow through the lymphatics

Back 6

-it is dependent on compressive forces along the lymphatics
-muscles, tissues, smooth muscle contraction of lymphatics walls

Front 7

how can you differ between edema and lymphedema

Back 7

-edema resolves after overnight elevation bc it is due to venous insufficiency

Front 8

why does edema commonly occur in the LE

Back 8

-because of the low number of alternate lymph pathways for drainage bc the outlet at the groin is narrowed by the lacunar ligament

Front 9

MC cause of lymphedema in the developing world

Back 9

-wuscheria bancrofti (filariasis nematode)

Front 10

MC cause of lymphedema in the US

Back 10

-malignancy and malignancy assoicated tx (radiotherapy and lymph node dissection)

Front 11

Elephantiasis verrucosa nostras

Back 11

-exaggerated form of secondary lymphedema that has been complicated by recurrent fungal and bacterial infections

Front 12

how do pts in the early stages of lymphedema clinically present

Back 12

-unilateral painless swelling
-usually strarts on the dorsum of the foot, with eventual proximal involvement in 1st year
-pitting edema

Front 13

how do pts in the late stages of lymphedema clinically present

Back 13

-pitting edema turns to non-pitting brawny edema due to subcut tissue becoming fibrotic
-skin then becomes hyperkeratotic, hyperpigmented and verrucous

Front 14

what is the Kaposi-Stemmer Sign

Back 14

-its positive in lymphedema
-examiner is unable to pinch a fold of skin at the base of the 2nd toe dorsal aspect

Front 15

the skin of lymphedema pts is ar risk for breakdown and subsequent infections...what types of infections are common

Back 15

-cellulitis
-erysipelas (Group A hemolytic strept cellulitis)
-tinea pedis
-lymphangitis

Front 16

what are DDx for lymphedema (other causes of painless edematous extremity)

Back 16

-venous insufficiency
-DVT
-renal failure
-hypoalbuminemia
-CHF
-pulmonary HTN
-obesity
-pregnancy

Front 17

diagnostic confirmation of lymphedema

Back 17

-isotopic lymphoscintigraphy

Front 18

list conservative tx options for lymphedema

Back 18

-compressiongarments/devices (triple layer in early stages)
-exercise
-manual lymph drainage

Front 19

when is sx used in lymphedema

Back 19

-when pts dont respond to traditional treatments
-surgeon can reconstruct lymphatics or debulk by reducing fluid and tissue

Front 20

for the most part surgical and drug therapies for lymphedema have proven unsuccessful, however VEGF has been proven to work in mice experiements to reduce lymphedema, what is the proposed mechanism

Back 20

-VEGF (vascular endothelial growth factor) has show to promote lymphangiogenesis

Front 21

what are the ultimate consequences of lymphedema and the subsequent stasis of lymph flow

Back 21

-this blunts regional immune trafficking, local inflammatory changes and a propensity for infection

Front 22

CDPT

Back 22

-complex decongestive physiotherapy
-this is really the only tx available for lymphedema
-a multicomponent technique of reducing limb volume with massage, maintaining health of skin, exercise and using compression after volume is reduced to maintain leg volume

Front 23

based on studies, what is the average reduction of lymphedema in pts that used CDPT for 9 months

Back 23

-volume reductions of about 60%

Front 24

why dont diuretics work for controlling lymphedema

Back 24

-because it is caused by elevated interstitial oncotic pressures due to macromolecules (protein), not retention of water and electrolytes

Front 25

signs of lymphatic failure

Back 25

-swollen limb w/o pain
-skin and subcut changes
-positive kaposi-stemmer sign
-fibrosis
-"mossy foot" from secondary bacterial and fungal infections

Front 26

Note: lymphedema is incurable and therefore treatment is palliative

Back 26

-

Front 27

what imbalance exists in lymphedema

Back 27

-imbalance between capillary filtration and lymph drainage

Front 28

if the edema subsides with overnight elevation it is probably not lymphedema; what is the cause though

Back 28

-increased capillary filtration
-when the legs are elevated, venous pressure is lowered and capillary filtration is lowered

Front 29

if a pt has painless leg swelling that just returned from a foreign country

Back 29

-ask them about filariasis

Front 30

unlike other forms of edema, lymphedema is not just simply fluid, there is a 'solid" component...consisting of

Back 30

-the accumulation of macromolecules (mainly protein and lipid) cannot escape from the tissues

Front 31

what recurrent infection is common in lymphedema

Back 31

-cellulitis/lymphangitis (from decreased lymph flow causing dec immune response)

Front 32

the larger lymphatic vessels or "collectors" towards the end of the lymph channels move lymph by smooth muscle contraction in the vesell wall, how do the smaller lymphatics move lymph towards the collectors

Back 32

-they rely on changes in tissue pressure (this is why compression stockings, exercise and massage are imp)

Front 33

what is another term for lymphedema

Back 33

elephantiasis (elephantitis when infected)

Front 34

what is the science behind multilayer bandaging for lymphedema

Back 34

-the short stretch bandages generate high pressure during muscular contractions but low pressure at rest

Front 35

hyperkeratosis of lymphedema can harbor microbes and increase risk of infection, how can this be prevented

Back 35

-aniseptic paints (castellani's) can be applied to folds and crevices to remove scale and control bacteria fungi

Front 36

although direct leaking of interstitial fluid may occur at points of minor trauma in lymphedema pts, it most often leaks from...

Back 36

-lymphangiomata (bulging lymphatics, like small blisters on the surface of the skin)

Front 37

smooth muscle contraction in the collector portion of the lymph system (carry lymph to nodes) depend on calcium influx; so what drugs could have a neg effect

Back 37

-calcium channel blockers (dilate the arteries)
-they are used for HTN, angina, abnormal heart rhythms
-simvastatin (zocor)
-lovastatin
-lipitor