• #13-1. Pathophysiology and Clinical Stages of Lymphedema


    Lymphedema is characterized by a localized build-up of the lymph due to weakened lymph dynamics. The interstitial fluid is integrated into the venous system through lymph glands, the only passage in the interstitial space. In lymphedema, the interstitial fluid is retained due to circulatory problems in the lymphatic glands and water, fat, proteins, and other residues accumulate.

    Lymphatic ducts can be divided into superficial and deep lymphatic ducts. Superficial lymphatic ducts form filigree patterns close to the skin surface and lack valves. The deep lymphatic system, on the other hand, locate above the fascia, course in the same direction as veins, have valves and sporadic lymph nodes. Lymphedema develops when the deep lymphatic system is compromised. The principle of the lymph drainage massage is to help the lymph retained in the superficial lymphatic system to circumvent the blockage and drain into normal lymphatic system.

    The clinical presentation of lymphedema is the build-up of protein-rich fluids in the interstitial space. Edema is caused by this build-up. With severe edema, the lymph becomes highly viscous and even doughy.

    Pitting edema is a key symptom of lymphedema and refers to the phenomenon where the pressure from the fingertip create a dent on the skin surface that persists for a few seconds. Nonpitting edema is observed in the last stage of edema. The affected area is hard to the touch and is not indented when pressure is applied.

    Secondary lymphedema generally affects the extremities such as the foot, ankle, hand or wrist, particularly after surgery. However, it can also develop in the inguinal region, thigh, shoulder or arm. Primary lymphedema can develop from a slight wound or infection of the limb due to congenital problems in the lymphatic system. Most cases of edema is resolved in time but lymphedema requires effective treatment and care as natural resolution is impossible and edema worsens with time.

    In lymphedema, lymphatic ducts and lymph nodes eventually become damaged. Fibrosis driven by accumulated protein-rich interstitial fluids causes the skin to thicken and harden. This reduces the oxygen and nutrition supply to cells and increases cellular metabolites. It eventually inhibits wound healing and creates an ideal environment for infection. Without proper treatment, lymphedema can cause significant physical and psychological pain due to loss of functionality of the affected area, muscular weakness, infection, skin diseases, and recurring infection, etc.

    Edema alone does not cause complications but if left untreated, lymphedema can become chronic and lead to various complications. The most common complication is skin problems which can be as severe as skin cancer and hyperkeratosis (which can cause the crust-like appearance of the skin). Necrosis can also occur in deep skin folds formed from severe swelling. It can be said that lack of treatment causes complications. Very severe cases can be fatal.


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    Self-diagnosis of lymphedema


    Signs of early stage lymphedema include the following;

    Stiffness or pressure: Many patients complain of a stiff sensation or pressure (the skin feels pulled and tense) in the early stages of lymphedema. A 30% increase of interstitial space is not noticeable with the naked eye. About 50% of patients with visibly progressed lymphedema reported having felt heaviness, stiffness and pressure as early signs.

    Edema: The size of the arm, leg or areas of the surgical site or radiotherapy increases. Edema can begin in the upper limb, breast, around the surgical wound, armpit, lower limb, lower abdomen, inguinal region or ankle.

    Pain: Throbbing pain in the arm or leg.

    Hotness: Hotness in the arm, leg or swollen area.

    Redness and inflammation: Infection can be suspected. When these signs are seen, seek medical attention immediately.

    Pitting: When pressed down with fingertips, the skin does not bounce up immediately and the dent persists for a few seconds. The dorsum of the hand or toes cannot be pinched (Stemmer’s sign).


    -To be continued-

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