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Causes of limb swelling
Bilateral pitting oedema
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Heart failure |
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Renal disease |
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Proteinuria |
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Cirrhosis |
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Carcinomatosis |
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Nutritional |
Painful unilateral pitting oedema
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Deep venous thrombosis |
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Superficial thrombophlebitis
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Cellulitis |
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Trauma |
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Ischaemia |
Painless unilateral oedema
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Post-phlebitic limb |
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Extrinsic compression
of the deep veins |
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Deep venous incompetence |
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Lymphoedema |
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Immobility |
Lymphoedema
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Lymphoedema presents with gradual
limb swelling |
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Due to progressive failure of lymphatic
system |
Primary lymphoedema
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Congenital (age <
1 year) - familial or non-familial |
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Praecox (age < 35
years) - familial or non-familial |
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Tarda (age > 35 years)
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Secondary lymphoedema
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Malignant disease |
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Surgery - axillary surgery or groin
dissection |
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Radiotherapy |
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Infection - parasitic (e.g. filariasis)
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Pathology
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Primary lymphoedema is the result
of a spectrum of lymphatic disorders |
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Can be due to aplasia, hypoplasia
or hyperplasia of lymphatics |
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In 80% obliteration of distal lymphatics
occurs |
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A proportion of patients have a family
history (Milroy's disease) |
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In 10% proximal occlusion of lymphatics
in abdomen and pelvis is seen |
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In 10% lymphatic valvular incompetence
develops |
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Chronic lymphoedema results in subcutaneous
fibrosis |
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Fibrosis can be worsened by secondary
infection |
Clinical features
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The initial presentation is usually
with peripheral oedema worse on standing |
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Begins distally and progresses proximally |
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Limb usually feels heavy |
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Can be unilateral or bilateral |
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Primary lymphoedema is more common
in women and is usually bilateral |
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With secondary lymphoedema the underlying
cause if often apparent |
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Examination shows non-pitting oedema |
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The skin often has hyperkeratosis,
fissuring and secondary infection |
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Ulceration is rare |
Investigations
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Chronic venous insufficiency
should be excluded with doppler ultrasound |
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Lymphoedema and its
cause can be confirmed with: |
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Lymphoscintigraphy |
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CT or MRI scanning |
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Lymphangiography |
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Lymphoscintigraphy is
usually the investigation of choice |
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Has a sensitivity >
90% and specificity of 100% |
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Normal lymphoscintigraphy
excludes a diagnosis of lymphoedema |
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Lymphangiography is
painful and rarely required |
Management
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The aims of treatment
are to: |
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Reduce limb swelling |
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Improve limb function |
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Reduce the risk of infection
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Conservative treatment
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General skin care will
reduce risk of infection |
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Swelling can be reduced
by elevation |
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Physiotherapy and manual
lymph drainage may help |
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External
pneumatic compression will also reduce
swelling |
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Once swelling is reduced
compression stockings
should be applied |
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Antibiotics should be
given at the first sign of infection |
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Drugs (e.g. diuretics)
are of no proven benefit |
Surgery
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Surgery consists of
two approaches |
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Debulking operations |
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Bypass procedures |
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Debulking operations
include: |
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Homan's operation - elliptical
excisions of skin and subcutaneous tissue with primary
closure |
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Charles' operation - radical
excision of skin and subcutaneous tissue with skin grafts |
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Both produce good functional
results |
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Cosmesis is often poor |
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Bypass operations include: |
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Skin and muscle
flaps |
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Omental
bridges |
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Enteromesenteric
bridges |
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Lymphaticolymphatic
anastomosis |
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Lymphaticovenous
anastomosis |
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