Lymphatic system

Question 1

Function of the lymphatic system

Answer 1

• maintains balance of fluids and fights infection
• absorb macromolecules that cannot go into the capillaries

Question 2

How do things flow in the lymphatic system and where do they drain

Answer 2

• pressure drives this system but there are some small muscles
• skeletal muscle contraction can help
• right UE + head = right subclavian
• everything else = left subclavian

Question 3

What are the components of the lympathic system

Answer 3

• lymph vessels
• lymph nodes
• spleen
• thymus gland
• tonsils
• peyer’s patches (small intestine)
• lymphocytes
• bone marrow

Question 4

Fluid exchange with capillaries and lymph vessels

Answer 4

• in CV system most filtrate reabsorbed at venous end
• 2-3% is NOT picked up
• this excess is transported as lymph in lymphatic vessels (use of valves)
• any fluid that exceeds the capacity of the venous removal is picked up by the lymphatics

Question 5

lymphangitis: defintion

Answer 5

• inflammation of the lymphatic vessel

Question 6

lymphadenitis: defintion

Answer 6

• inflammation of one or more lymph nodes

Question 7

lymphedema

Answer 7

• an increased amount of lymph fluid in the soft tissues
• results in accumulation or protein rich fluid in EXTRACELLULAR spaces

Question 8

lymphadenopathy

Answer 8

• enlargement of the lymph nodes

Question 9

Lymphedema cause

Answer 9

• decreases lympathic transport capacity or increased lympathic load/blockage

Question 10

Stage 0 lymphedema

Answer 10

• Lymph transport capacity is reduced;
• no clinical edema present;
• symptomatic complaints possible

Question 11

Stage 1: lymphedema

Answer 11

• Accumulation of protein rich, pitting edema
• Reversible with elevation
• Area affected may be normal size on walking in the morning
• Increases with activity, heat and humidity

Question 12

Stage 2: lymphedema

Answer 12

• accumulation of protein rich non-pitting edema with CT scaring
• Irreversible
• Does not resolve overnight
• Increasingly more difficult to pit
• Clinical fibrosis is present
• Skin changes present

Question 13

Stage 3: lymphedemia

Answer 13

• Lymphostatic elephantiasis
• Accumulation of protein-rich edema with significant increase in connective and scar tissue.
• Severe non pitting fibrotic edema.
• Atrophic changes (hardening of dermal tissue, skin folds, skin papillomas, and hyperkeratosis

Question 14

Usualy signs and symptoms of lymphedema

Answer 14

• Slow onset, progressive
• Pitting (early stages)
• Stemmer’s sign positive (try to pinch and can’t = positive)
• Dorsum of foot buffalo hump
• Rarely painful, however discomfort (heaviness and achiness) is common
• Skin changes in the LE lymph-edema may include hyperkeratosis, papillomas
• In contrast with venous disease the skin maintains hydration and elasticity for longer in the disease process

Question 15

What can go along with lymedema

Answer 15

-Cellulitis is common due to back up of fluid

Question 16

Edema grading scale

Answer 16

• Grading scale for pitting edema
  1+ there is barely detectable 2 mm depression; not easily seen but can be felt. Immediate rebound
  2+ There is a 4 mm deep pit. A few seconds to rebound
  3+ there is a 6 mm deep pit. 10-12 seconds to rebound
  4+ There is an 8 mm deep pit ( very deep) > 20 seconds to rebound

Question 17

Lymph Angiodysplasia:

Answer 17

• Varicosity
• Hema-angioma: discolorations; vessels stretched
• Neurological changes due to increase pressure

Question 18

Pathogenesis of lymphedema: decreased absorption of lymph

Answer 18

1. intralympathic pressure increases
2. lymph oozes into the wall of the lymphatics and into the perilymphatic tissues
3. lymphangiosclerosis (hardening)
4. lymph pump deterioration
5. low output failure: lymphedeme

Question 19

Pathogenesis of lymphedema: subtotal lympatic blockage

Answer 19

1. remaining lympathics increase their pumping activity
2. intralympathic pressure increases
3. Dilation of valvular insufficiency
4. lymph oozes into the wall of the lymphatics and into the perilymphatic tissues
5. lymphangiosclerosis (hardening)
6. lymph pump deterioration
7. low output failure: lymphedeme

Question 20

Clinical manifestations of Lymphedema

Answer 20

• positive stemmers sign
• full, heavy, tight sensation
• numbness, burning, aching, pain
• decreased flexibility
• difficulty with clothing/jewelry fitting
• increased girth and weight
• impaired speech, swallowing respiration (Swelling in face/neck)
• atrophic skin cahnges

Question 21

Complications of lymphedema

Answer 21

• atrophic skin changes
• keratotic patches
• lymphatic fluid leakage
• toe fungus
• functional impairments

Question 22

Medical management of lymphedema: diagnosis

Answer 22

• primary = stemmers sign
• secondary = medical history
• unilateral = doppler US
• CT/MRI
• lymphoscintigraphy (dye - newer)
• fluorescence lymphography
• magnetic resonance lymphangiography

Question 23

medical management of lymphedema treatment

Answer 23

• coordinated care
• medication s
• surgery to debulk

Question 24

PT clinical assessment with lymphedema

Answer 24

• caution with BP cuff
• Thorough history and systems review
• skin assessment
• pain, paresthesias, sensory impairments
• photographs
• functional impairments

Question 25

Lymphedema PT interventions

Answer 25

- manual lymph drainage - multilayer short-stretch compression bandaging - exercise (muscle pumping) - Compression garments - compression pumps - education - psychological and emotional support

Question 26

Comprehensive Lymphedema management:

Answer 26

- Initially intensive phase - Once it is stage 2 it is not reversible - Optimization (maintence) phase - Manual lymph drainage - Compression badaging - Short-stretch compression bandaging - Long-stretch compression bandaging - Maintaining proper pressure gradient - Exercise guidelines - Compression garments - Education and home program - Importance and adherence - Compression pumps: intermittent - - - Pneumatic compression - Skin care - Guidelines for job and lifestyle modifications - Psychosocial considerations and quality of life - Low level laser therapy

Question 27

Lymphagenitis/lymphangitis and cellulitis medical management

Answer 27

- diagnosis Hx - treament: - rest immobilization, cold - oral antibiotics or IV

Question 28

Lipedema clincal manifestations

Answer 28

- symmetric swelling from fatty deposits from hips to ankles - primarily women - bruisability due to pressure breaking capillaries - pain/heavy feeling - orthostatic edema - dieting does not change tissue

Question 29

lipedema stage 1

Answer 29

- skin soft and regular - palpable nodules (fatty deposits)

Question 30

lipedema stage 2

Answer 30

- skin soft and regualr - nodules tought, fatty lobules - pitting edema - skin color changes

Question 31

stage 3 lipedema

Answer 31

- massive fat deposition

Question 32

Lipedema medical management - diagnosis

Answer 32

- diagnosis: - (-) stemmers sign - symmetric swelling - dieting doesnt help - lymphoscintigram (dye)

Question 33

lipedema medical mangement - treatment

Answer 33

- symptomatic relief - functional improvement - compression garments

Question 34

Venous edema

Answer 34

- some pittin g - brawny - hemosiderin staining - ulcers medial malleolus - fibrosis of subcutaneous tissue - atrophic skin

Question 35

Acute deep vein thrombosis clinical manifestation s

Answer 35

- sudden onset - unilateral - cyanosis - positive homans sign - potentially lethal disease - venous doppler (US)

Question 36

Congestive heart failure Clinical manifestations

Answer 36

- edema is greatest distally - pitting edema always bilateral - complete resolution with elevation (early) - no pain - orthopnea, PND, dyspnea on exertion - jugular venous distension

Question 37

CHF diagnosis

Answer 37

- physical exam, - CXR - cardiac echo

Question 38

Malignant lymphedema | Clinical manifestations

Answer 38

- pain, paresthesia, paralysis - central location (proximal onset) - rapid development, continuous progression - swelling and nodules in supraclavicular fossa - hematoma like discoloration - ulcers, non-healing wounds - recurrent malignancy - sole presenting symptom of new malignancy