Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area.
The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).
The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.
Primary lymphoedema is a rare, genetic condition, which usually presents before aged 30. It is a result of faulty development of the lymphatic system.
Secondary lymphoedema is due to a separate condition that affects the lymphatic system. The most common example is when patients develop lymphoedema after breast cancer surgery, due to the removal of axillary lymph nodes in the armpit.
Lipoedema is an important differential diagnosis, where there is an abnormal build-up of fat tissue in the limbs, often the legs. The feet are spared in lipoedema, unlike lymphoedema. This affects women more often than men. It can cause pain, psychological distress and significantly affect the patient’s quality of life.
Assessment
Stemmer’s sign can be used to assess for lymphoedema. The skin at the bottom of the second toe or middle finger is gently pinched together using two fingers. If it is possible to lift and “tent” the skin, Stemmer’s sign is negative. If it is not possible to pinch the skin together, lift and “tent” it, Stemmer’s sign is positive, suggesting lymphoedema.
Limb volume can be calculated using:
- Circumferential measurements at various points along the limb
- Water displacement (putting the limb into water and measuring the volume of water displaced)
- Perometry (a square frame with perpendicular light beams is moved along the limb, measuring the outline and volume)
Bioelectric impedance spectrometry can be used to measure the volume of fluid collected in the limb. Electrodes are placed on the limb, and an electrical current is passed through the limb, between the electrodes. The resistance to electrical flow through the tissues estimates the volume of lymph fluid in the tissues.
Lymphoscintigraphy is a type of nuclear medicine scan. A radioactive tracer is injected into the skin, and gamma cameras (scintigraphy) are used to assess the structure of the lymphatic system.
Management
A specialist lymphoedema service manages patients with lymphoedema.
Non-surgical treatment options include:
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
Lymphaticovenular anastomosis is a surgical procedure that involves attaching lymphatic vessels to nearby veins, allowing the lymphatic vessel to drain directly into the venous system. This and other surgical procedures are occasionally used where other treatments fail.
Antibiotics are required if cellulitis (infection in the skin) develops.
Cognitive behavioural therapy and antidepressants can be used to manage any psychological impact of having lymphoedema.
TOM TIP: Avoid taking blood, inserting a cannula, giving injections or performing a blood pressure reading in a limb with lymphoedema.
Lymphatic Filariasis
Lymphatic filariasis is an infectious disease caused by parasitic worms spread by mosquitos. The worms live in the lymphatic system where they can cause damage, leading to severe lymphoedema. This severe lymphoedema is associated with thickening and fibrosis of the skin and tissues, and is referred to as elephantiasis. It is most common in the tropics of Africa and Asia.
Last updated May 2021