Lymphedema: Difference between revisions
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* Feeling of heaviness, tightness, or discomfort | * Feeling of heaviness, tightness, or discomfort | ||
* May be pitting at onset | * May be pitting at onset | ||
* | * Severe cases have dermal thickening with skin becoming dry, firm, and hyperkeratotic | ||
** Occurs due to cutaneous fibrosis and adipose deposition. | ** Occurs due to cutaneous fibrosis and adipose deposition. | ||
* Stemmer Sign - positive if unable to pinch and lift skin at the base of second toe or finger. | * Stemmer Sign - positive if unable to pinch and lift skin at the base of second toe or finger. | ||
| Line 44: | Line 44: | ||
* Acute deep vein thrombosis | * Acute deep vein thrombosis | ||
* Post-thrombotic Syndrome | * Post-thrombotic Syndrome | ||
* Hypoalbuminemia | |||
* Congestive Heart Failure | |||
* Limb Hypertrophy | * Limb Hypertrophy | ||
** Hypertrophy of soft tissue or bone (Klippel-Trenaunay syndrome) | ** Hypertrophy of soft tissue or bone (Klippel-Trenaunay syndrome) | ||
| Line 52: | Line 54: | ||
==Evaluation== | ==Evaluation== | ||
* Diagnosis is primarily made clinically. See clinical features above. | |||
* Additional studies | |||
** Duplex Ultrasound | |||
** Lymphoscintigraphy | |||
** Computed Tomography | |||
** Magnetic Resonance Imaging/Lymphography | |||
** Indocyanine Green (ICG) Lymphangiography | |||
** Genetic Testing | |||
===Clinical Staging (by International Society of Lymphology)=== | |||
* Stage 0 - Asymptomatic, swelling not evident despite impaired lymphatic transport. May have feeling of heaviness in limb. | |||
* Stage I (mild) - Soft edema +/- pitting, no sign of dermal fibrosis, fluid accumulation subsides with limb elevation within 24 hours. | |||
* Stage II (moderate) - Some dermal fibrosis present, not reversible with limb elevation alone. | |||
* Stage III (severe) - Lymphostatic elephantiasis, skin changes such as fat deposits, acanthosis, warty overgrowths. | |||
==Management== | ==Management== | ||
* General Measures | |||
** Self-monitoring - for size, sensation, color, temperature, skin condition | |||
** Limb elevation | |||
** Diet and exercise - maintain ideal body weight. Recommended to use compression garments during exercise. | |||
** Avoid skin infection/injury | |||
* Compression Therapy - bandaging, garments, intermittent pneumatic compression | |||
* Physiotherapy - manual lymphatic drainage | |||
** Contraindicated in presence of cellulitis, neoplasm, DVT, moderate-severe heart failure | |||
* Surgical Referral | |||
==Disposition== | ==Disposition== | ||
Revision as of 03:22, 2 October 2017
Background
- Lymphedema is due to abnormal accumulation of interstitial fluid and fibroadipose tissue.
- Occurs with lymphatic load exceeds capacity in the lymphatic system
Etiology
Primary
- Congenital Lymphedema (6-12%) - before age 2
- Lymphedema Precox (77-94%) - at onset of puberty
- Lymphedema Tarda (11%) - after age 35
Secondary
- Cancer and cancer treatment (Lymphadenectomy, Radiotherapy)
- Breast Cancer - most common
- Sarcoma
- Lower Extremity Melanoma
- Gynecologic Cancer
- Genitourinary Cancer
- Head and neck cancer
- Infection
- Lymphatic Filariasis
- Tuberculosis
- Recurrent Skin Infections (eg. Cellulitis, Erysipelas)
- Lymphadenitis
- Obesity
- Inflammatory disorders
- Dermatitis
- Sarcoidosis
- Arthritis
- Rheumatoid Arthritis
- Psoriatic Arthritis
- Juvenile Idiopathic Arthritis
- Dermatitis
Clinical Features
- Slowly progressive swelling
- Feeling of heaviness, tightness, or discomfort
- May be pitting at onset
- Severe cases have dermal thickening with skin becoming dry, firm, and hyperkeratotic
- Occurs due to cutaneous fibrosis and adipose deposition.
- Stemmer Sign - positive if unable to pinch and lift skin at the base of second toe or finger.
Differential Diagnosis
- Venous Insufficiency
- Acute deep vein thrombosis
- Post-thrombotic Syndrome
- Hypoalbuminemia
- Congestive Heart Failure
- Limb Hypertrophy
- Hypertrophy of soft tissue or bone (Klippel-Trenaunay syndrome)
- Overgrowth of body part (Proteus Syndrome)
- Myxedema
- Lipedema
- Tumor
Evaluation
- Diagnosis is primarily made clinically. See clinical features above.
- Additional studies
- Duplex Ultrasound
- Lymphoscintigraphy
- Computed Tomography
- Magnetic Resonance Imaging/Lymphography
- Indocyanine Green (ICG) Lymphangiography
- Genetic Testing
Clinical Staging (by International Society of Lymphology)
- Stage 0 - Asymptomatic, swelling not evident despite impaired lymphatic transport. May have feeling of heaviness in limb.
- Stage I (mild) - Soft edema +/- pitting, no sign of dermal fibrosis, fluid accumulation subsides with limb elevation within 24 hours.
- Stage II (moderate) - Some dermal fibrosis present, not reversible with limb elevation alone.
- Stage III (severe) - Lymphostatic elephantiasis, skin changes such as fat deposits, acanthosis, warty overgrowths.
Management
- General Measures
- Self-monitoring - for size, sensation, color, temperature, skin condition
- Limb elevation
- Diet and exercise - maintain ideal body weight. Recommended to use compression garments during exercise.
- Avoid skin infection/injury
- Compression Therapy - bandaging, garments, intermittent pneumatic compression
- Physiotherapy - manual lymphatic drainage
- Contraindicated in presence of cellulitis, neoplasm, DVT, moderate-severe heart failure
- Surgical Referral