[lymph + edema]
An abnormal accumulation of tissue fluid in the interstitial spaces due to the removal of lymph nodes or to the blockage or destruction of lymphatics. Stagnant flow of tissue fluid through body structures may make them prone to infections that are difficult to treat; as a result lymphedematous limbs should be protected from cuts, scratches, burns, and blood drawing.
LYMPHEDEMA OF THE LEG
SEE: lymphatic blockade; SEE: elephantiasis; SEE: lymphedema pump
Common causes of lymphedema include neoplastic obstruction of lymphatic flow (as in the axilla, in metastatic breast cancer); postoperative interference with lymphatic flow (after axillary dissection); infectious blockade of lymphatics (in filariasis); radiation damage to lymphatics (after treatment of pelvic, breast, or lung cancers). All of these are secondary (acquired) lymphedemas. Rarely, lymphedema also may occur congenitally (Milroy disease), or develop at the onset of puberty or during adulthood from an unknown cause that may be related to vascular anomalies (primary lymphedema). In the U.S. and other developed countries, the leading cause of secondary lymphedema is surgical or radiation therapy for cancer, esp. if accompanied by lymph node dissection.
SYMPTOMS AND SIGNS
Symptoms of lymphedema include a feeling of heaviness, tiredness, aching, weakness, and fullness in a limb that impairs flexibility or interferes with the wearing of jewelry, watches, or clothing.
The clinical appearance of affected limbs is diagnostic.
Lymphedema occurs in four stages, 0 to 3: 0) the subclinical stage in which lymph transport is known to be impaired, but no signs or symptoms are obvious (this stage may last for years); 1) soft tissue with pitting edema; swelling decreases with elevation; 2) swollen tissue but firmer and thus may not show pitting; edema does not resolve completely with elevation; and 3) grossly enlarged and misshapen limb; skin breakdown and infection often occur.
Surgical techniques that spare lymphatic drainage and the integrity of uninvolved lymph nodes reduce the incidence of postoperative lymphedema, e.g., in patients with breast cancer who undergo axillary dissection to remove tumor that has spread to neighboring lymph nodes.
Postoperative physical therapy reduces the severity of lymphedema, as do lymphatic drainage techniques and bandages and clothes that compress the limb. Drugs such as antibiotics, anticoagulants or diuretics are not effective.
A combination of manual lymphatic drainage, compression devices, and protection of the affected limb can make a positive difference in a patient’s quality of life. Patient management by physiatrists, other physicians experienced in lymphedema care, certified nurses, and therapists is crucial. Careful measurement of the affected limb with comparison to its opposite and diagnostic testing help to rule out other causes. If necessary, lymphangioscintigraphy can be used to examine the anatomy and functioning of the lymph system. Patients and their partners can be taught effective techniques to use at home. Compression devices are fitted over the affected limb to help maintain or reduce swelling. Compression pumps use air or fluid pressure to mimic massage’s beneficial effects. They are designed to move lymphatic fluid back toward functional nodes by providing sequential, even pressure from the distal to the proximal portions of the affected limb. Compression sleeves or stockings should be fitted by a professional because an improperly fitted device may irritate skin and other tissues and result in additional swelling.
Sensible weight reduction programs based on mild caloric restriction and gentle exercise help alleviate symptoms. Overexertion of affected limbs should be avoided. Using the affected limb for activities of daily living (bathing, hair-brushing) helps to drain lymph fluid. Supporting the arm on the back of a chair or couch provides helpful elevation for lymph drainage. In acute care settings, the affected limb should be identified by the patient and by health care providers with a loose-fitting, colored (bright pink) armband to ensure that blood drawings, injections, and blood pressure readings are not done on that limb. Skin should be kept clean and moisturized to limit chapping or chafing leading to breakdown. The patient is taught to avoid cuts and abrasions, as when using kitchen knives or other implements, to wear gloves when gardening, and to wash and inspect skin after such activities, and to clean any skin breaks that occur, treating them with an antibacterial cream or ointment and a sterile dry dressing. In cases of lower extremity edema, sitting with the legs in a dependent position, crossing the legs, or standing for prolonged periods should be avoided. Extremes of heat and cold exposure should be avoided. The health care provider should be notified if the limb develops a rash or itching or pain or if the patient develops fever or flulike symptoms. Local support groups can assist patients in dealing with body image issues and fitting clothing to asymmetrical limbs. Resources for further information on lymphedema management include The National Lymphedema Network and other support organizations such as the American Cancer Society.
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