Lymphedema

Lymphatic system is a major part of the circulatory and immune system that transports lymph fluid from tissues to the blood stream. Lymph fluid contains white blood cells that protect the body against infections and help the body detoxify. When lymph fluid is not drained properly and starts to build and cause swelling, it is called Lymphedema. Any part of the body can be affected by Lymphedema, but it usually occurs in the arms, legs and very rarely it can occur on the neck, head, groin and genital areas.

Primary Lymphedema is congenital and is caused by the defective lymphatic system present during the birth. Sometimes primary Lymphedema, though present during the birth, may surface only after puberty.

Secondary Lymphedema is an acquired lymphedema due to infection, trauma, injury or cancer that has disturbed the lymphatic system. Apart from such conditions, radiation therapy and surgery involving lymph nodes also results in malfunction of lymphatic system giving rise to Lymphedema. Women who are treated for breast cancer are at high risk for Lymphedema. Breast cancer surgery normally involves removal of one or two lymph nodes and thus disturbs the pathway of the lymphatic system. Hence breast cancer patients should be watchful of any swelling under arms or around the breast region after the surgery.

Symptoms of Lymphedema

1. Pain and heaviness in the arms, legs, chest and breast.
2. Swelling in the arms and legs including fingers and toes.
3. Hardening and redness on the skin of the affected limbs.
4. Tingling sensation or pins and needles feeling in the arms and legs.
5. Sore feeling in elbow.
6. Trouble in wearing jackets, watches, bracelets and rings.
7. Difficulty in moving the limbs.
8. Discolored skin associated with rash.
9. Skin indentation after pressing the affected region.
10. Fever

Diagnosing Lymphedema

Doctor evaluates the patient through clinical examination and also checks family and medical history of the patient. He will also look for risk factors such as history of a cancer or a surgery. Doctor may also look for pitting by gently applying the pressure on the swelling. If skin indentation occurs, it needs to be examined further. Certain imaging tests like CT scan, MRI, Lymphoscintigraphy and ultrasonography may be carried on to confirm Lymphedema.

Lymphedema treatment

Treatment for Lymphedema depends upon the extent of progression and severity of the disease. However, the following methods are broadly followed to treat Lymphedema:

Manual lymph drainage: Manual lymph drainage is a massage technique that allows the flow of lymph from affected limb. This technique helps to heal the diseased portion, restore the health of the skin and also treat the infection.

Wrapping/Bandaging: Wrapping the arm or leg with layered bandage is the most effective way of treating Lymphedema. Lymph vessels lie below the skin and take the help of the muscles to drain the lymph. The bandage wrapped around the limb provides good support to the muscles and thus fluid is pumped out easily. Bandages should be wrapped tightly around the fingers and toes and loosened as you go up the arm.

Compression garments: Compression garments are specially designed garments and they work much the way as wraps do. These garments reduce the swelling and also prevent it from recurring. They help the muscles in pushing the lymph into lymph vessels by providing firm support. Compression garments should be picked up under professional guidance with utmost care as the proper fit is essential in treating the Lymphedema. Once purchased, they should be worn regularly and all day long for speedy results.

Exercise: Certain decongestive exercises increase the lymph flow and allow it to flow back into the blood stream. Exercise sets in the movement in muscles and thereby helps in draining the lymph fluid easily. The rate of lymph flow is 15 times higher during exercise when compared to the resting period. Thus, swelling eases faster with specified exercise regimen. Always take the help of the Lymphedema therapist before starting the exercises as not all types of exercises are suitable for Lymphedema patients.

Pneumatic compression: This is a new compression device that works towards reducing swelling rapidly. It is a plastic garment with electrical pumping unit which inflates with pumped air and thus applies pressure on the muscles. These muscles in turn work on the lymphatic flow and thus reduce the swelling.

Drugs: If the affected area is infected, doctor may prescribe antibiotics to control the infection. Painkillers are also administered to relieve the patient from pain.

Fibrosis

The formation of excess fibrous connective tissue between the cells of various organs or tissues as a reactive process is called fibrosis. It can cause stiffening or hardening of tissues in skin, internal organs and joints. It can be reactive, pathological or in a benign state. When fibrosis arises from a single tissue, it is called Fibroma and in response to an injury it is called scarring.

Fibrosis may occur in many tissues within the body due to damage or inflammation, examples include:

• Pulmonary Fibrosis, affecting the lung
  
• Cystic Fibrosis affecting the mucus glands
  
• Heart Fibrosis, affects the heart that is damaged post myocardial infarction
  
• Liver Cirrhosis, accumulation of tough, fibrous scar tissue in the liver
  
• Bone marrow Fibrosis, affects the bone marrow and prevents normal production of blood cells
  
• Mediastinal Fibrosis, blocks respiratory channels and blood vessels due to calcified fibrosis of the lymph nodes
  
• Skin fibrosis, due to the formation of scar tissues due to injury.

Fibrosis formation

During the early stages of Lymphedema, tissues swell with protein-rich lymph that may not drain properly. The tissues are soft to touch; this condition is known as pitting edema. There is pressure on these tissues pushing the fluid aside thus leaving an indentation. If left untreated at this stage, the lymph may become fibrotic thus forming fibrosis. As fibrosis develops, the normal tissues are replaced by the scar-like structures that cause hindrance to lymph drainage. Fibrosis can occur in slightly swollen tissues too. As the lymph cannot drain properly, it leads to accumulation of protein molecules in the tissues thus increasing formation.

Fibrosis causes

• It may be caused by a disease or while treating the disease.
  
• Other causes could include burns, injuries, chemotherapy, radiation and gene mutation.
  
• It is also possible that the causes may remain idiopathic, i.e. the cause is unknown.
  

Effects of fibrosis

Symptoms of fibrosis can vary depending on the location and severity of the condition. Common symptoms include scarring.

• Fibrosis will harden the affected tissue, at times they also swell. These changes can make the tissues incapable of functioning properly; the fluid flow through these affected tissues might be reduced. When present in the lungs, the lung is unable to expand adequately leading to shortness of breath.
  
• Fibrosis of joints can cause pain and stiffness of the affected joint.
  
• Fibrosis in the shoulder may lead to frozen shoulder.
  
• Fibrosis of the tendons may lead to deformity of fingers and hand.

Edema

Edema previously known as hydropsy is a condition where the soft tissue is swollen because of the accumulation of interstitial fluid. Abnormal accumulation of the interstitial fluid presents a noticeable swollen appearance in various areas of the body. The fluid moves from the vascular region to the interstitial region because of preexisting conditions. The distribution of edema in different areas of the body is an effective diagnostic factor to identify various underlying conditions. Edema is broadly classified in to two categories, localized and generalized respectively.

Localized edema

Localized edema is predominantly caused because of the obstruction caused in the lymphatic or venous system. In some cases these edemas can be fatal as they induce conditions such as deep vein thrombosis and allergic reactions like angioedema. Angioedema is also known as non-pitting edema. Localized edema can also occur due to neoplasm and also because of inflammation associated with infections.

Generalized edema

Generalized edema is caused because of impaired cardiac or renal function. Fluid retention and increase in the concentration of sodium may result in the swelling of various body parts. This type of edema can also occur because prolonged sitting or standing in one position. The sodium retention associated with renal impairment is generally caused because of vasoconstriction. In conditions such as cirrhosis of the liver, the edema is generally noticed in the peritoneal region which is referred to as ascites. Edema associated with cardiac impairment is usually associated with the right side of the heart and the left side impairment leads to pulmonary edema. Shortness of breath is often associated with edema.

Clinical manifestations and causes associated with edema

Edema (oedema) occurs because of various preexisting health conditions. Any variation in the vital parameters of the body such as fluid imbalance, venous pressure fluctuations and lymphatic impairments lead to edema. Protein insufficiency and hepatic disease increases the occurrence of edema. Many women experience episodes of edema during pregnancy. This happens because of increased fluid distribution to nourish the developing child and mother at the same time. Some forms of edema also occur because of increased capillary permeability. Conditions such as vasculitis and post-anoxic encephalopathy cause increased capillary permeability.

Pitting edema is also one if the important types of edema which occurs in some people who wear tight outfits. The regions covered by the tight clothing generally swells up and after a certain period of time, the tissue returns to the normal appearance. In addition to the conditions mentioned, edema is also caused because of certain drugs. Drugs which block the calcium channels, corticosteroids, birth control pills and antidepressants predominantly induce the onset of edema.

Edema requires medical attention as it may lead to many other complications. The complications associated with edema are swelling with pain, stretched skin with dryness, formation of scarred tissue, and risk of skin ulcers and decreased elasticity of the arteries, veins and muscles.

Diagnosis and Treatment of Edema

Diagnosis of edema is done by identifying the underlying causes associated with it. Complete biochemical analysis is done to identify the factors such as hyperthyroidism, protein insufficiency and fluid electrolyte ratios. Pregnant women are generally advised to avoid standing for prolonged period of time especially during the last trimester of their pregnancy. Patients suffering from consistent edemas are advised to keep in an elevated position with some support. Loose and comfortable clothing is also recommended as it helps in the uniform blood circulation.

Treatment for edema includes dietary restriction of sodium flowed by the administration of diuretics. Diuretics are predominantly used in conditions such as lymphedema, renal disease and obstruction in the venous flow. Since edema is also associated with weight loss, the administration of diuretics has to be reduced once the patient reaches optimal weight.