Lymphatic System

The portion of interstitial fluid that enters the lymphatic system:

lymph

Nodes, tonsils, thymus, spleen, thoracic duct, bone marrow:

lymphatic organs

Submaxillary, cervical, axillary, iliac, mesenteric, inguinal, popliteal, cubital, supraclavicular, parasternal:

major lymph nodes

Flow of Lymph:

1. Fluid is transported from lymphatic capillaries

2. Lymphatic collecting vessels

3. Along the length of these vessels, lymph nodes occur to filter the lymph

4. Lymphatic trunks

5. Lymphatic collecting ducts

6. Subclavian veins

Amount of lymphatic fluid transported:

lymphatic load

Maximum amount of fluid that lymphatic system can transport:

transport capacity

Lymphatic load > transport capacity =

lymphedema

A patient presents with lymphedema post mastectomy. All of the following are causes of secondary lymphedema EXCEPT which cause?

A. Infection
B. Milroy’sdisease
C. Fibrosis
D. Chronic venous insufficiency

Chronic disorder characterized by an abnormal accumulation of lymph fluid in the tissues of one or more body regions:

lymphedema

Primary Lymphedema:

Congenital or genetic/ hereditary abnormalities in the lymphatic system

• Congenital Lymphedema: Milroy disease

• Lymphedema Praecox (Meige disease)

• Lymphedema Tarda

Secondary Lymphedema:

Injury to one or more components of the lymphatic system

• Lymph node removal

• Infection

• Tumor

• Trauma

• Chronic venous insufficiency

• Fibrosis

• Filariasis

Pitting edema:

• Pressure on the edematous tissues with the fingertips causes an indentation of the skin that persists for several seconds after the pressure is removed.

• This reflects significant but short duration edema with little or no fibrotic changes in skin or subcutaneous tissue.

Brawny edema:

• Pressure on the edematous areas feels hard with palpation.

• This reflect a more severe form of interstitial swelling with progressive, fibrotic changes in subcutaneous tissues.

Weeping edema:

• This represents the most severe and long duration form of lymphedema.

• Fluids leaks from cuts or sores; wound healing is significantly impaired.

• Lymphedema of this severity occurs almost exclusively in the lower extremities

Stemmer’s Sign:

• A positive Stemmer’s sign, an indication of stage II or III lymphedema

• Positive if the skin on the dorsal surface of fingers or toes can not be pinched (lifted) or is difficult to pinch compared with the uninvolved limb

• A positive Stemmer’s sign is indicative of a worsening condition

Stages of Lymphedema:

• Stage 0 (Latency)

• Stage I (Reversible Stage)

• Stage II (Spontaneously Irreversible)

• Stage III (Lymphostatic Elephantiasis)

Stage 0 (Latency):

• No clinical edema, occasional reports of heaviness

• Stemmer’s sign negative

• Tissue and skin appears normal

Stage I (Reversible Stage):

• Edema present (soft and pitting)

• Edema increases with standing and activity but reduces on elevation

• Stemmer’s sign negative

Stage II (Spontaneously Irreversible):

• Hard swelling present; progresses to non-pitting ”brawny” edema

• Stemmer’s sign positive (although still may be negative at early stage II)

• Tissue appears fibrosclerotic; proliferation of adipose tissue

Stage III (Lymphostatic Elephantiasis):

• Edema present; severe ”brawny” nonpitting edema

• Stemmer’s sign positive

• Skin changes (papillomas, deep skinfold, warty protrusions,

  hyperkeratosis, mycotic infections, etc.)

• Repeated bacterial and viral infections are common

A patient with lymphedema presents with notable swelling that is hard and fibrotic, has a positive Stemmer’s sign, and hyperkeratosis of skin. Which of the following stages of lymphedema would the patient MOST LIKELY be in?

A. Stage 0

B. Stage I

C. Stage II

D. Stage III

Pitting edema scale: 1+

Mild, barely perceptible indentation; <1/4-inch pitting

Pitting edema scale: 2+

Moderate, easily identified depression; return to normal within 15 seconds; 1/4-to-1/2-inch pitting

Pitting edema scale: 3+

Severe, depression takes 15 to 30 seconds to rebound; 1/2-to-1-inch pitting

Pitting edema scale: 4+

Very Severe, depression lasts for >30 seconds or more; >1 inch pitting

A clinician is evaluating a patient with lymphedema and documents it is an “early-stage II lymphedema with pitting edema grade 3+”. Which of the following statements MOST APPROPRIATELY describes the clinical presentation?

A. The indentation produced is greater than 1 inch
B. The indentation on finger pressure lasts for less than 15 seconds

C. The indentation on finger pressure lasts for 20 seconds
D. The indentation produced is less than 1/2 inch

Which of the following signs would indicate INITIAL development of lymphedema in a patient seen post radical mastectomy with axillary node removal?

A. Non-pitting edema of the forearm
B. Shallow wound beds on the forearm
C. Atrophy of the biceps muscle
D. Decreased range of motion of the fingers

Lipedema:

• Lipedema is a bilateral condition affecting the lower extremities

• Lipedema affects the proximal areas, such as the buttocks and thighs, but not distal areas, such as the feet

• Lipedema affects skin’s elasticity, the skin sensitive to pressure and touch, which makes it bruise easily and painful

A clinician is evaluating a patient with lipedema. Which of the following is MOST LIKELY seen as patient’s presentation?

1. Patient is susceptible to bruising of the affected area

2. Patient would have a positive Stemmer’s sign

3. Patient has a high likelihood of developing cellulitis

4. Patient would have asymmetrical involvement of the lower

   extremity