Kembara Xtra - Medicine - Lymphedema Lymphedema can appear when lymphatic vessels are missing or compromised (primary) or when lymph vessels are injured or lymph nodes are eliminated (secondary), which causes an accumulation of lymphatic fluid in the interstitial tissue and swelling. 80% of the time, external genitalia, the face, the trunk, and the lower limbs are affected. Epidemiology Incidence The majority of breast cancer patients (13%) underwent surgery; 42% underwent surgery and radiation therapy; 25% underwent GYN cancer surgery; Milroy disease, which is thought to affect between 1/6,000 and 1/300 live births; and Meige disease, which appears during adolescence. Prevalence Primary lymphatic filariasis affects 120 million individuals globally. Nonfilarial secondary lymphedema affects approximately 10 million persons in the US. Pathophysiology and Etiology Secondary lymphedema: Risk is higher with postoperative radiation because radiation inhibits duct regrowth due to fibrous scarring; postoperative: progressive failure of distal lymphatics, which must "pump" lymph at a higher pressure through damaged proximal ducts. Lymphangiogenesis suppression and tissue fibrosis enhancement by T cells appear to increase lymphedema, as do trauma, recurrent infection, malignancy, including metastatic illness, and significant obesity. The most prevalent cause in developing nations is filariasis (Wuchereria bancrofti). Genetics Lymphedema praecox begins between the ages of 1 and 35 years. Milroy disease is an autosomal dominant condition that can be detected at birth or within the first year of life. People older than 35 are more likely to develop tardive lymphedema. Referral for genetics: main and tarda lymphedema Risk Elements Prior trauma, severe burns, infection of the affected limb Obesity (>50 body mass index) Inflammatory disorders: arthritis, sarcoidosis, dermatitis Filariasis, the most prevalent cause globally Lymphadenectomy or radiation therapy for malignancy (mastectomy, melanoma) Prior trauma, serious burns, infection of the affected limb Prevention Maintaining a healthy body weight, treating congestive heart failure, identifying infections and malignancies early, and treating venous insufficiency Accompanying Conditions Filarial disease (Africa and Asia), venous illness, severe obesity, and localized cancer History Vein stripping, a recent procedure, can drastically worsen mild lymphedema. A feeling of heaviness in the limb, especially at the end of the day and in hot conditions, is the first sign. clinical assessment Initial: pitting edema; spreads proximally or distally; Later: nonpitting; spreads radially after the first year; Hyperkeratosis (thicker skin); Papillomatosis (rough skin); Increase in skin turgor; Positive Stemmer sign (inability to pinch the skin of the dorsum of the second toe between the thumb and forefinger); false positives are uncommon. Multiple Diagnoses Hypoalbuminemia, protein-losing nephropathy, chronic venous illness, postoperative problems following ipsilateral surgery, cellulitis, Baker cyst, and idiopathic edema are some of the conditions that can occur. Laboratory Results Lack of response to diuretic or elevation therapy could signify lymphatic insufficiency. Diuretics reduce plasma volume, venous capillary pressure, and filtration by increasing excretion of salt and water. Diuretics reduce filtration edema but do not permanently enhance lymph drainage. There are a few pertinent protein biomarkers for lymphedema that have been discovered and they appear promising for latent- and early-stage diagnosis. Initial examinations (lab, imaging) Comprehensive chemistry panel: hepatic or renal impairment; TSH: hypothyroidism; urine test: protein-losing nephropathy; ultrasound: assesses for acute/chronic DVT; provides information about soft tissue changes but does not reveal the truncal anatomy of the lymphatics; duplex ultrasound: lymphedema causes gradual obstruction of venous return that aggravates the edema; 82% of patients with unexplained limb edema were Tests in the Future & Special Considerations Fluorescence microlymphography may be extremely sensitive (91.4%) and specific (85.7%), non-traumatic, and radiation-free in the diagnosis of leg lymphedema. Lymphangiogram: direct cannulation of lymphatics through the skin; risk for infection, local inflammation; now rarely used. Lymphoscintigram: radiolabeled protein technetium-99m-labeled colloid that measures lymphatic function, lymph movement, lymph drainage, and response to treatment. Indocyanine green lymphography: reported to be superior to lymphoscintigraphy in early diagnosis of the arm. Accurately screens for subclinical lymphedema after surgery. CT scan: thickening of the SC comp. and calf skin. Management Aim for a healthy weight; treat cellulitis quickly; avoid damage to the affected area (direct injury, venipunctures, improper nail care, extremely hot or cold temperatures). Maintain limb size while mechanically reducing it with the help of professionals wearing compression clothing. Elevate the injured limb or area, but do not stop moving. Keep affected limbs free of BP cuffs and other focused restriction. Use emollients for skin care and daily cleaning to prevent skin infections. Varicose veins can sometimes be treated non-surgically, and it's unlikely that flying is related to larger limb volumes. Medication Caution There is no evidence that any drugs, not even diuretics, are useful in treating lymphedema. Referral For manual decongestive therapy, consult a physical therapist who has received lymphedema training. - Before beginning comprehensive decongestive therapy in patients with recurrent or metastatic disease, talk with the oncologist to avoid encouraging the growth of the disease. Teach the patient and family how to administer therapy on their own in the future. Bandage education for the family Compression garment fitting Further Therapies Exercise causes the intrathoracic pressure to decrease during inspiration, which in turn causes lymph to flow. Combining flexibility, strength, and aerobic exercise yields the best benefits. Compression with a specially made elastic stocking (minimum pressure is 40 mm Hg) - Protection against external incidental trauma - Reduces intrinsic trauma on the skin brought on by chronically elevated interstitial pressures that stretch the skin and SC tissues - No data on whether custom-made or prefabricated stockings are preferable - Replace every three to six months or when the elastic begins to lose its elasticity. Multilayer bandaging: inner layer of tubular stockinette, followed by foam and padding to protect the joint flexures and even out the contours of the limb so that pressure is distributed evenly; outer layer of at least two shortstretch extensible bandages; more effective than hosiery alone. Pneumatic pumps develop high pressures like systolic BP and can significantly reduce limb girth; wear a compression sock after (2)[A]. Advanced pneumatic compression devices (APCDs) are programmable, provide a more customized fit, lower cellulitis rates by at least 75%, and, depending on the healthcare context, lower early treatment expenses by 37-54%. Surgical Techniques Low-level laser therapy has been shown in smaller studies to be noninferior to manual lymphatic drainage or in combination in arm volume reduction among breast cancer patients in half the treatment time. Bypass procedures: Creation of lymphatic-venous anastomosis or lymph node transplantation (most effective) via microsurgery showed a reduction in use of conservative compression therapy. In certain preclinical breast cancers, axillary reverse mapping during axillary node dissection can drastically lower lymphedema incidence. A novel treatment for breast cancer-related lymphedema, thoracic sympathetic ganglion block, improved life quality and resulted in >50% arm size reduction, particularly in patients with high-grade lymphedema. Debulking techniques (Charles procedure) involve the aggressive removal of SC tissue and primary or staged skin grafting. Men fared less well than women in these surgeries. - Infection and necrosis of the skin graft provide the greatest danger. - Liposuction is preferred over debulking in terms of aesthetics. Admission Systemic signs of infection - Patients with severe pulmonary illness or heart failure may be admitted to a specialized rehabilitation facility for a combination of treatments - IV antibiotics for infection; cellulitis is most prevalent. Encourage the patient to move around and exercise by situating the affected extremity with some distal elevation. Discharge requirements: - Improved signs or symptoms of infection (such as an elevated WBC count, fever, or abnormal vital signs) - Clinical improvement in wound appearance Take Action If the patient quits wearing compression clothing throughout the day and bandaging at night, the lymphedema will return in a few days. Patient monitoring; daily therapy appointments for immediate care; monthly maintenance visits Diet Lower salt, wholesome protein, and (if necessary) weight loss-focused Education of Patients Wear compression clothing, especially when working out. In order to prevent being dependent on the damaged limb(s) for extended periods of time, the patient should undertake daily skin examinations. Prognosis There is no cure, although treatment can work well with regular maintenance. Complications Risk of wound formation (punctures/abrasions) that are difficult to heal: common Infection (local vs. systemic): common Lymphangiosarcoma: seen in lymphedematous arms of patients after radical mastectomy, as well as in individuals with Milroy disease. For individuals with specific non-metastatic disease, radiation is used with surgery as a kind of treatment.
0 Comments
Leave a Reply. |
Kembara XtraFacts about medicine and its subtopic such as anatomy, physiology, biochemistry, pharmacology, medicine, pediatrics, psychiatry, obstetrics and gynecology and surgery. Categories
All
|