Lymphoedema
Classification
- Primary (Milroy's disease)
- Congenital disease / primary lymphatic failure
- 3 times more common in women
- Pathology originates within lymphatics
- Secondary
- Malignant infiltration of nodes
- Infections - filiaris (Wuchereria Bancrofti worm), TB
- Post radiotherapy / post surgery - axillary dissection in breast
Approach
- Expose legs
- Preserve dignity
- Inspect
- Grossly swollen, no particular distribution
- Tends to be bilateral
- Note loss of contour of ankle
- May be lichenified fronds on the toes and skin looks thick and indurated
- Yellow discolouration of nails
- Palpate
- Determine pitting or non-pitting?
- Initially oedema characteristically pitting but later stops pitting as tissue resistance increases
- Palpate groin for inguinal lymphadenopathy
- Percuss
- Auscultate
Completion
- Examine JVP, heart, lungs to exclude Right heart failure
- Palpate liver for hepatomegaly
- Ask patient to determine any hereditary conditions that predispose to lymphoedema
Differential diagnosis of swollen legs
- Central
- Right heart failure, hypoalbuminaemia, nephrotic syndrome, hypothyroidism
- Peripheral
- Klippel-Trenaunay syndrome, chronic venous insufficiency, post phlebitic limb
- Rare
- AV malformations (Parkes-Weber)
Treatment options for lymphoedema
- Non-surgical
- Grade III compression stockns
- Intermittend pneumatic compression device
- Leg elevation (reduces intravascular hydrostatic pressure and stockings increase extracellular hydrostatic pressure)
- Surgical
- Rarely used - results tend to be poor
- Likely to be successful where there is discreet occlusion of lymphatics
- Options: lymphovenous anastamosis, debulking of leg
- Kondolean procedure (1912) - resection of subcutaneous lymphoedematous tissue
- Charles procedure (1912) - resection of subcutaneous lympoedematous tissue down to muscle fascia with skin grafts taken from the resected specimen
- Homans-miller procedure (1932) -
- Thompson procedure
