Pathology- Lymphatic System

lymphatic system

pressure driven system based on the principles of osmosis

lymph

a clear, watery fluid originating in the organs and tissues of the body that circulates through the lymphatic vessels and is filtered by the lymph nodes

fats, proteins, cell debris

what does lymph carry

lymphedema

if transport of lymph is disrupted, water and protein can remain in the tissue space and result in

transport lymph fluid and balance fluid levels, removal of proteins from interstitial space, production of lymphocytes (WBC) for immune function

what is the purpose of the lymphatic system

neck, axilla, inguinal region

where are the major areas for lymph nodes

gland, bone marrow, spleen, liver, appendix, tonsils, peyer patches of the small intestines

what are lymphatic organs and tissues

open system with no central pump

the lymphatic system is an

lymph vessels

involved in the formation of lymph, absorb interstitial fluid and return to venous circulation

lymph organs

part of the body's defense system (secondarily involved in virtually all systemic infections)

high pressure to low pressure

until equilibrium is reaches, lymph fluid flow from an area of

hydrostatic pressure is greater than tissue pressure

lymph fluid at the arterial end of capillaries will tend to flow into the tissue spaces when the

lymphatic dysfunction

results in part or all of the 10% fluid volume and proteins remaining trapped in tissue spaces

rhythmically

muscle in the collecting lymphatic walls contracts

extrinsic muscle contractions

can help with pumping the fluid into the lymph system

ineffective smooth muscle contraction, vessel failure

too high of intravascular pressure fatigues the muscle wall and leads to

closure of valves

high pressure causes walls to dilate, preventing the

backflow of lymph distal to the site of obstruction

when the walls dilate and prevent closure of valves what happens

truncal or genital edema

improper treatment can result in the development of

lymphangitis

inflammation of a lymphatic vessel

lymphadenitis

inflammation of one or more lymph nodes

lymphedema

an increased amount of lymph fluid in the soft tissue; asymmetric swelling of the soft tissues from an accumulation of protein rich fluid in the extracellular space

lymphadenopathy

enlargement of the lymph nodes

decreased lymphatic transport capacity or increased load

what causes lymphedema

extremities

lymphedema is commonly seen in

head, neck, abdomen, genitalia

lymphedema is commonly seen in the extremities but can occur in the

primary or secondary

lymphedema can be either

primary lymphedema (Milroy’s disease)

hereditary condition of the lymphatic system that develops with swelling beginning in the feet and progressing into the ankles and in an upward direction along the legs; due to the failure of the lymphatic system formation

secondary lymphedema

caused by damage to lymphatic vessels that is most frequently due to cancer treatment, surgery, trauma, or burns

hyperplasia (large vessels), hypoplasia (limited number of lymph nodes), aplasia, other

what causes primary lymphedema

surgery (removal of lymph nodes, liposuction), radiation to lymph nodes, trauma (burns and multiple pregnancies), parasites, cancers/lymphomas, infection, obesity

what causes secondary lymphedema

lymphoscintigraphy

most accurate method to identify blockage and to diagnose lymphedema

doppler ultrasound

can also indicate edema, but not as accurate or difinitive

full sensation in the affected body part/heaviness, fatigue of the affected extremity, sensation of skin tightness, decreased flexibility in the hand, wrist, or ankle, difficulty fitting into clothing in one specific area, ring, wristwatch, or bracelet tightness

clinical signs and symptoms of lymphedema

increased limb girth, postural changes, tremendous discomfort, integumentary wounds, atrophic skin, fungal infections, decreased strength, decreased ROM

resulting impairments

increased impairments

what happens with progressive stages of lymphedema

stage 0

early changes within the tissues without obvious noticeable swelling or symptoms. protein molecules can accumulate beneath the skin and "pull" extra water into the affected area, occasionally resulting in sensations of heaviness or fatigue in the limb or region. despite "normal" measurement of tissue or limb sizes in the area, the early changes leading to lymphedema have begun and generally respond to treatment.

months or years

how long may stage 0 last before any obvious lymphedema occurs

no

should stage 0 of lymphedema be ignored

worsening edema

prompted treatment during stage 0 will reduce the risk of

negative

is the stemmers sign negative or positive during stage 0

stemmer's sign

a thickened fold at the base of the second toe or second finger that is a diagnostic sign for lymphedema

tissue cannot be lifted but can only be grasped as a lump of tissue

a positive stemmer sign is when the

possible to lift the tissue normally

a negative stemmer sign is when it is

ruling in

stemmer's sign is good for

ruling out

a stemmer's sign is bad for

stage 1

puffy appearance of the hand or foot (distally). there may be pitting edema, but often not. it may be more difficult to see veins on the top of hand or foot. it is not unusual for swelling to improve at night but return during the day.

temporarily reduce edema

elevation of limb during stage 1 may

negative

during stage 1 of lymphedema is stemmer sign positive or negative

stage 2

swelling takes on a spongy consistency and pitting edema and does not respond to elevation. the tissue consistency change is caused by the formation of fibrosis, or scar tissue, with gradual thickening of the tissues on the limb as it increases in size

positive

is the stemmer sign positive or negative in stage 2

stage 3

skin typically becomes dry and scaly and the limb or other affected body region becomes very large. there may be fluid leaking from the limb and skin infections are common. the weight of the limb can be debilitating. excess skin projections can from to attempt to contain the fluid, and these projections pose an even greater infection risk, severe non-pitting edema

positive

is the stemmer sign positive or negative for stage 3

no cure, treatable, requires lifelong management

prognosis of lymphedema

do not take BP on arm with diagnosed (or suspected) lymphedema, individuals should avoid needles in the extremity (ies), application of heat modalities, any extreme temperatures (hot or cold), protect their limbs from sun and injury, dont cross legs (if in LE), avoid tight clothing

contraindications with lymphedema

avoid drinking a lot of water, avoid drinking alcohol or caffeine, low salt diet

other considerations for those with lymphedema

manual lymph drainage (message), short stretch compression bandaging, custom compression garments, intermittent compression pump, exercise, lower risk activities, education

typical PT interventions for lymphedema

compression garment or compression bandage on

exercise should always be performed with a

lipoedema

symmetrical "swelling" of both legs, hips, to both ankles (foot not involved)

deposits of subcutaneous adipose tissue

what causes lipoedema

pitting edema as the day progresses

signs and symptoms of lipoedema

typically in women, family history

risk factors of lipoedema

morbid obesity

lipoedema is usually misdiagnosed as

hypersensitivity increases

as lipoedema progresses, what happens

unilateral

how does edema present with lymphedema

bilateral LE

how does edema present with venous insufficiency

bilateral LE

how does edema present with lipoedema

bilateral LE and abdomen (ascites)

how does edema present with congestive heart failure

maybe pain, maybe color chain, fibrous tissue in stage 3 and 4, high risk of infection, foot and hands involved, skin mobility is restricted, positive stemmer sign in 3 and 4, unilateral edema

characteristics of lymphedema

maybe pain, hemosiderin staining, chronic fibrosis, high risk of infection, foot is likely involved, skin mobility is restricted, possible positive stemmer sign, bilateral LE edema

characteristics of venous insufficiency

pain, bruising, no tissue fibrosis, low risk of infection, no foot involvement, skin mobility within functional limits, negative stemmer sign, bilateral LE edema

characteristics of lipoedema

no pain, no color change, no tissue fibrosis, no risk of infection, foot is involved, skin mobility is within normal limits, negative stemmer sign, bilateral LE and abdomen edema

characteristics of congestive heart failure

DVT, arthritis

other causes of unilateral edema

renal failure, liver disease, severe lung disease

other causes of bilateral edema

areas of high concentration to lower areas when equilibrium is reached

Lymph Fluid flows from

results in part of all the fluid and proteins being trapped in the interstitial spaces (accounts for about 10% of fluid volume)

Lymphatic dysfunction

fatigue in the muscle walls that leads to ineffective smooth muscle contracture and vessel failure

Two high of intravascular pressure leads to

occurs before 35

Lymphedema Praecox

occurs after 35

Lymphedema Tarda

DVT, Arthritis

Unilateral Edema Misdiagnosis

renal failure, liver disease, severe lung disease

Bilateral edema misdiagnosis