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13.02.28 Lymphoedema

Swelling differential
  • Fluid
  • Overgrowth
  • Tumour
  • Shrinkage of t'other side


Fluid flow

  • Net pressure is OUT OF capillaries over their entire length
    • => There is no venous reabsorption of fluid
    • => Lymphatics do it all
  • NB this is not what used to be taught


Lymphatic failure

  • Filtration oedema
    • Lymphatics still functional, just overloaded
    • e.g. In acute heart failure
    • Pits easily as fluid is still flowing fine
  • Lymphoedema
    • Damage to lymphatics
    • e.g. From sustained filtration oedema
    • Pits at early stages
    • Non-pitting later on


Lymphoedema stages

  • Stage 0 (latent):
    • Vessel damage but transport capacity is still sufficient for the amount of lymph being removed
    • Lymphedema not present
  • Stage 1 (spontaneously reversible)
    • Tissue is still at the "nonpitting" stage
    • Usually upon waking in the morning, the limb or affected area is normal or almost normal in size
  • Stage 2 (spontaneously irreversible)
    • The tissue now has a spongy consistency and is considered "pitting"
    • Fibrosis found in stage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size
  • Stage 3 (lymphostatic elephantiasis)
    • Swelling is irreversible and usually the limb(s) or affected area is very large
    • The tissue is hard (fibrotic) and unresponsive


Milroy's disease

  • VEGFR-3 mutation => Spontaneous oedema


Distinguishing features of lymphoedema (vs filtration oedema)

  • Only slightly helped by elevation
  • Diuretics don't help
  • >1 attack of cellulitis
    • Due to reduced immune cell trafficking
  • Exercise helps
  • Pitting
  • Skin thickening/hyperkeratosis


Notes

  • Lymphatics
    • Small collecting ducts
    • Large draining ducts, with valves + smooth muscle
  • Don't confuse lipodermatosclerosis with cellulitis
    • Requires elevation and compression, not antibiotics
  • CCBs block lymphatic smooth muscle pumping and can cause lymphoedema
  • Plexiform neurofibroma
    • Brown spots + swollen leg
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