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Lymphoedema.

Lymphoedema is a condition in which the intercellular spaces within the tissues contain an abnormal amount of lymph, leading to the obstruction of lymph drainage system (Weller, B.F. 2005). Interstitial fluid is a clear watery, straw coloured fluid similar to blood plasma, which circulates through the porous capillary walls into the interstices or spaces between the cells that form the tissues. A certain amount of this fluid returns back through the capillary walls, with the excess returning back to the blood via the lymphatic system. The term lymph means once the interstitial fluid has entered the lymphatic system. Any fluid not removed by the lymphatic system from the interstitial spaces leads to oedema. This build-up of fluid leads to both pain and a lack of mobility within the patient, with the arms and legs commonly affected by oedema (Watson, R. 2005).

It is thought that up to 90% of interstitial fluid is reabsorbed into the venous capillaries' via colloid pressure (the pressure exerted by the large molecules in the blood, draining fluid into the bloodstream from the surrounding tissue). While the lymphatic system reabsorbs the remaining 10% of fluid (Waugh, A et al 2001). During a 24 hour period between 2-4 litres of interstitial fluid is returned to the circulatory system via the lymphatic system, compared to 8-16 litres via the vascular system (Wigg, J. 2010).

The lymphatic system is responsible for the development of both immunity and the resolution of infections (Waugh, A. et al 2001). Lymphoedema may be due to a congenital abnormality of the lymphatic vessels--Milroy's disease is a congenital lymphoedma of the legs. Or it can be due to an obstruction of the lymphatic vessels by a tumour, parasite, inflammation or injury (Concise Medical Dictionary).
ISL                 Description

ISL stage 0         A subclinical state where swelling is not evident
                    despite impaired lymph transport. This stage may
                    exist for months or years before oedema appears.

ISL stage 1         This represents the early onset of the condition
                    where there is accumulation of tissue fluid that
                    subsides with elevation. The oedema may be
                    pitting at this stage.

ISL stage 11        Limb elevation alone rarely reduces swelling and
                    pitting is manifest.

ISL late stage 11   There may or may not be pitting, as tissue
                    fibrosis.

ISL stage 111       The tissue is hard (fibrotic) and pitting is
                    absent. Skin changes such as thickening,
                    hyperpigmentation, increased skin folds, fat
                    deposits and warty overgrowths develop.

(Cooper, G. 2012).


Primary lymphoedema or Milroy's disease is caused by the failure or the absence of lymphatic vessels in embryotic life. It is either seen in isolation or with other congenital abnormalities i.e. Turners Syndrome. Oedema development is insidious and depending on age at onset will reflect the degree of failure. There are 2 main categories that Milroy's disease falls into either primary or idiopathic lymphoedema (Menz, H.B. 2008).

There are 3 different subtypes;

* Congenital lymphoedema--appears at or near birth (Milroy's disease).

* Lymphoedema praecox--typically appears at puberty and before 35 years (Meige disease).

* Lymphoedema tarda--appears after the age of 35. thought to be caused by a defect in the lymphatic valves. (Lorimer, D. et al 2006).

Secondary lymphoedema is due to the obstruction of the lymphatic system caused by trauma, surgical intervention, invasive tumours, radiotherapy or filarial infestation (parasitic worms that affect the human connective and lymphatic tissue) (Menz. H.B. 2008).

Clinical presentation and diagnosis is based on patient history, clinical signs and symptoms. Swelling is the most common factor affecting the limbs and other bodily parts. The swelling is generally resistant to compression--non pitting-than venous oedema. Therefore is less commonly associated with ulceration and hyperpigmentation, with advanced cases hardening of the skin and subcutaneous tissue is common (Menz. H.B. 2008). Lymphangiograms is a definitive test to confirm lymphatic obstruction (Lorimer, D. et al 2006).

In primary lymphoedema the age of onset varies, while in secondary lymphoedema it depends on the cause. Both sexes are affected in primary lymphoedema with females making up to 70-80% of all cases.

* 10% of cases of oedema are present from birth.

* 80% of cases present before the age of 35.

* 10% of cases present in the over 35.

* In 80% of primary cases develop in one lower limb. (Lorimer, D. et al 2006).

Initially, the oedema is of the pitting type, elevation of the limb leads to a reduction in oedema. Over time the pitting becomes non--pitting and indurated due to fibrous. The epidermis is classically 'warty and hyperkeratotic in appearance', leading to opportunistic infections in 20% of cases (Lorimer, D. et al 2006). With 50% of patients complaining of pain or discomfort, usually described as aching or heaviness within the limb (Menz. H.B. 2008).

The International Society of Lymphology has identified a 5 point staging for the level of lymphoedema within the patient.

There is no known cure for lymphoedema, except management of the condition. The best treatment option is to reduce congestion. Management includes compression bandaging, exercise and manual lymph drainage along with maintaining the integrity and pliability of the skin. Compression hosiery can be used as a stand-alone treatment once the initial multi-layer bandaging has been removed, as this prevents excess fluid buildup with in the limb (Menz. H.B. 2008).

Skin care has been acknowledged to both maintain and improve skin integrity and suppleness. both during and after treatment (International Lymphoedema Framework 2006). The general principles of skin care include:

* Daily washing of the skin with a PH--neutral soap, natural soap or substitute and dry thoroughly.

* Any skin folds especially round the ankle are both clean and dry.

* The skin is checked for any cuts, abrasions or insect bites and action taken.

* Emollients applied avoiding scented products.

Other treatments options include;

* Eliminating any underlying cause's i.e. chronic infection.

* Limb elevation and exercise.

* Pneumatic massaging devices i.e. Flowton Boots.

* Diuretic therapy.

* Microsurgical techniques to improve drainage (Lorimer, D. et al).

References

Concise Medical Dictionary.3rd Ed Oxford University Press.

Cooper, G. (2012) Lymphoedema treatment in palliative care: a case study. British Journal of Nursing, 21 (15), p.897-903.

International Lymphoedema Framework. (2006) International Consensus. Best Practice for the Management of Lymphoedema Medical Educational Partnership. Available through: www.woundsinternational.com/pdf/content-175.pdf [Accessed: 7th Dec 2012].

Lorimer, D. French, G. O'Donnell, M. Burrow, J. G. Wall, B. (2006) Neales Disorders of the Foot. 8th ed. Churchill Livingstone Elsevier.

Menz, H.B. (2008) Foot Problems in older People. Assessment and Management. Churchill Livingstone Elsevier.

Watson, R. (2005) Anatomy and Physiology for Nurses.12th Ed. Elsevier.

Waugh, A. Grant, A. (2001) Ross and Wilson: Anatomy and Physiology in Health and Illness. 9th ed. Churchill Livingstone. London.

Weller, B.F. (2005) Bailliere's Nurses' Dictionary for Nurses and Health Care Workers. 24th ed.

Wigg, J. (2012) Medical Lymphatic Drainage and Lymphoedema Management. Leduc. Cannock.

Michelle Taylor BSc., M.Inst.Ch.P
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Title Annotation:Technical Article
Author:Taylor, Michelle
Publication:Podiatry Review
Article Type:Disease/Disorder overview
Geographic Code:4EUUK
Date:May 1, 2013
Words:1136
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