Lymphedema

Introduction to lymphedema Lymphedema refers to the soft tissue fluid caused by the reflow of lymphatic fluid in some parts of the body. The subcutaneous fibrous connective tissue hyperplasia after repeated infection on the surface of the body, fat hardening, if the limb is thickened, the skin is thickened, rough, and tough as skin. Also known as " elephant skin swelling." The Chinese medicine doctor called "no name swelling". basic knowledge The proportion of illness: 0.012% Susceptible people: no specific population Mode of infection: non-infectious Complications: pulmonary embolism

Causes of lymphedema

(1) Causes of the disease

Primary lymphedema (Milroy's disease) is a dominant hereditary disease, which may be related to abnormal embryonic development. Secondary lymphedema is caused by malignant tumor compression, surgical destruction, radiation exposure, filariasis, lymph node resection, and Lymphatic occlusion occurs due to factors such as infection, and lymphedema occurs locally after several months or even years. Lymphedema is common in the tropics, but sometimes it is impossible to find a cause. In some countries, filariasis causes lymphedema. One of the reasons is that the effect of bacterial infection on lymphatic obstruction is not certain, but recurrent erysipelas and chronic cellulitis can damage the lymphatic vessels and further accelerate the development of the disease. Similar lesions can be found in tissues surrounding chronic ulcers.

(two) pathogenesis

Lymphatic tissue is the interstitial fluid in the intercellular space. It is returned to the vein through the lymphatic vessels. The lymphatic circulation is also the physiological and functional physical circulation of the human body. The lymphatic system is congenital dysplasia or occlusion or destruction for some reason. Obstruction, abnormal lymphatic fluid in the interstitial space, if the limbs are affected, the limbs are evenly thickened. At first, the skin is smooth and soft, and the edema of the affected limb can be obviously subsided. Because the accumulated lymph is rich in protein, it can be as high as 5.8. g/dl, [normal 0.72g/dl] long-term stimulation causes abnormal growth of connective tissue, adipose tissue is replaced by a large amount of fibrous tissue, skin and subcutaneous tissue are extremely thickened, skin surface is keratinized, rough, and no indentation occurs after finger pressure. Symptoms increase the body, forming a typical "like skin swelling", the infection increases the inflammatory exudate, stimulates a large number of connective tissue hyperplasia, destroys more lymphatic vessels, aggravates lymphatic retention, increases the chance of secondary infection, and forms malignant The circulation causes lymphedema to become more and more serious.

Histopathology: The main lesion of primary lymphedema is in the reticular reticular layer and subcutaneous tissue. There are more lymph fluid in the interstitial space, and the collagen fibers in the dermal papilla are transparent and degenerated. There are different degrees of lymphocyte infiltration around the blood vessels. In the early stage of secondary lymphedema, there is inflammatory cell infiltration, advanced tissue fibrosis, and its epidermis is verrucous hyperplasia.

Lymphedema prevention

For secondary lymphedema, there are two types of people who are susceptible, and those who have experienced malignant tumors (such as breast cancer, ovarian cancer, uterine cancer, prostate cancer, colon cancer, bladder cancer, melanoma) radical surgery And patients with radiation therapy; the other is patients who often have skin "ang venom" attacks.

The first type of patients should avoid the skin damage of the affected limbs after surgery. Do not take injections on the affected limbs, pay attention to the cleanliness of the skin. In addition, patients with filarial infections are also susceptible people. If edema is found, seek medical attention immediately.

The second type of patients should actively treat the originating factors that cause infection, such as athlete's foot and strengthen the body's resistance. If you find that the skin is red and hot or the body has a similar cold, you should immediately use antibiotics to control the development of inflammation. It is found that the back of the foot is swollen and should be taken seriously. Get medical attention as soon as possible.

In short, early diagnosis, early treatment, to prevent the development of lesions, local elastic bandage bandaging, prevention of secondary infection is important to prevent further development of the lesion.

Lymphedema complication Complications pulmonary embolism

(1) Incision infection, lymphatic leakage.

(2) systemic reactions: fever, nausea, vomiting, due to allergic reactions to contrast agents may produce peripheral circulatory failure.

(3) Local lymphatic reactive inflammation, which makes lymphedema worse.

(4) Pulmonary embolism: The contrast agent may increase in pressure through the collateral branch into the vein, causing pulmonary embolism, the incidence rate is 2 to 10%, the literature has been reported due to pulmonary embolism.

Lymphedema symptoms Common symptoms Traveler edema Skin rough Chronic ulcer Lymphatic dysplasia Chronic high hot water bubble nausea edema Lymphoid hyperplasia

The causes of lymphedema are numerous, considering the etiology and clinical type. They are mainly divided into primary and secondary types. Most of the primary lymphedema is caused by congenital dysplasia such as lymphatic vessel dilatation, valve insufficiency or absence. According to lymphangiography, primary lymphedema can be classified as follows: 1 lymphatic hypoplasia with subcutaneous lymphoid deficiency; 2 lymphatic hypoplasia, small lymph nodes and lymphatic vessels; 3 lymphoid hyperplasia with lymph nodes and lymphatic vessels More, there are distortions and varicose veins, in which lymphatic dysplasia is very rare, common in congenital lymphedema, development is less than the most common type, simple and spastic lymphedema is congenital, early onset lymphedema is more common in adolescence Female or young women, the symptoms of menstrual period worse, it is speculated that the cause may be related to endocrine disorders, accounting for 85 to 90% of primary lymphedema, after the age of 35, it is called delayed lymphedema, secondary lymphedema Most of them are caused by lymphatic obstruction. The most common in China is filariasis lymphedema and streptococcal infectious lymphedema. Upper extremity after radical mastectomy Lymphedema is not uncommon.

classification:

(a) primary lymphedema

1. Congenital: simple, hereditary (milroy disease);

2. Early onset.

(B) secondary lymphedema

1. Infectivity: parasites, bacteria, fungi, etc.;

2. Injury: surgery, radiotherapy, burns, etc.;

3. malignant neoplasms: primary tumors, secondary tumors;

4. Others: systemic diseases, pregnancy, etc.

According to the cause classification, their respective clinical characteristics are described as follows:

(1) Congenital lymphedema is divided into two categories:

1. Simpleness: no family or genetic factors in the disease, the incidence rate accounts for 12% of primary lymphedema. After birth, there is one limb limitation or diffuse swelling, no pain, no ulcer, few concurrent infections, generally good. More common in the lower limbs.

2. Hereditary: Also known as Milroy's disease, it is rare. Many people in the same family are sick, that is, after the birth, most of them are affected by one lower limb.

(2) Early onset lymphedema: more common in women, male to female ratio 1:3, age of onset 9 to 35, 70% is unilateral, generally mild swelling of the ankle and foot, standing, activity without obvious inducement Increased menstrual period and climate warming, refers to the high edema of the affected limb can be temporarily relieved, the lesion gradually worsens and spread to the calf, but generally does not exceed the knee joint, the late can be a typical "like skin leg", but rarely with ulcers and subsequent Infected.

(3) Infectious lymphedema: including bacteria, fungi, filarial infections, cracks in the skin of the toes or blisters are the most common routes of invasion of pathogenic bacteria, followed by secondary varicose veins with secondary ulcers and other local injuries or infections. Pathway of bacterial invasion, in addition, pelvic lymphadenitis caused by female pelvic inflammatory disease can cause lymphatic reflux in the lower limbs and cause lymphatic swelling of the affected limb. It has also been reported that streptococcus is the most common pathogen of secondary infection, clinically recurrent acute cellular It is characterized by inflammatory inflammation and acute lymphangitis. It has severe systemic symptoms, chills, high fever and nausea, vomiting, local sulcus lymphadenopathy with tenderness. The systemic symptoms are resolved quickly by anti-inflammatory symptomatic treatment, but local lesions are relieved slowly. Repeatedly, the swelling of the lower extremities is aggravated after each episode, and finally the skin is rough and has a sickle-like growth, and a few can be followed by chronic ulcers.

The foot lice itself or secondary infection also causes lymphedema, which is generally limited to the foot and the back of the foot. Severe fungal infections are often a precursor to acute cellulitis and acute lymphangitis. Controlling fungal infection is one of the effective measures to prevent lymphedema.

Filaria sensation is a common cause of lower extremity lymphedema in the southeastern coastal areas of China. The incidence rate is 4 to 7%. It is more common in men. There are different degrees of fever and local pain in the early stage of filarial infection. Repeated filarial infection causes local lymphatic stenosis in the lower extremities. Occlusion, destruction, the distal skin and subcutaneous tissue lymphatic drainage is blocked, lymphedema, localized lesions such as athlete's foot or secondary erysipelas-like recurrent attacks, causing lymphatic drainage to be blocked and infection as a causal effect, forming a vicious circle and eventually becoming Typical " elephant skin legs", its flash, scrotal lymphedema is not uncommon, the late can cause extreme swelling of the scrotum, which is also a major feature of filarial infectious lymphedema.

(D) Injury lymphedema: mainly divided into postoperative lymphedema and lymphedema after radiotherapy.

1. Postoperative lymphedema: often occurs after lymph node dissection, the lymphatic edema of one side of the upper limb caused by radical mastectomy is especially common, the distal lymphatics are blocked after extensive lymph node dissection, the lymph fluid stimulates tissue fibrosis, and the swelling continues Aggravation, the time of lymphedema after surgery is quite different. Generally, the limbs begin to move and there is mild swelling of the proximal limb, but it can also occur several weeks or even months after surgery.

2. Lymphedema after radiotherapy: deep X-ray and radium infusion therapy caused local tissue fibrosis, lymphatic occlusion caused by lymphedema.

(5) Malignant neoplastic lymphedema primary and secondary lymphoid malignancies can block lymphatic edema in the lymphatic vessels. The former is found in Hodgkin's disease, lymphosarcoma, Kaposi multiple hemorrhagic sarcoma and lymphangisarcoma, lymphatic Although sarcoma is rare, it is the result of long-term lymphedema and malignant transformation. It occurs mostly in patients with lymphedema after limbectomy. It usually occurs 10 years after surgery. The skin first appears red or purple spots, which is multiple. After the fusion into an ulcerative mass, the limb lymphedema is more serious after the onset, should be timely biopsy, amputation is required after the diagnosis is clear.

Secondary lymphatic lesions are metastases of breast, cervix, labia, prostate, bladder, testis, skin, internal iliac and other cancers. Sometimes the primary lesion is small and difficult to detect. The clinical manifestations are chronic meridian, no Painful, progressive lymphedema, therefore, for lymphocytes edema of unknown cause, should be alert to the possibility of tumor, if necessary, lymph node biopsy to confirm the diagnosis.

In addition, pregnancy and many systemic diseases such as pneumonia, influenza, typhoid, etc. can also lead to recurrent cellulitis and lymphangitis, as well as venous thrombosis and lymphatic obstruction leading to lymphedema.

Lymphedema examination

(1) Analysis of diagnostic puncture tissue fluid

The analysis of subcutaneous edema tissue fluid is helpful for the differential diagnosis of difficult cases. The protein content of lymphedema fluid is usually very high, generally 1.0-5.5g/dl, but venous stasis, heart failure or hypoproteinemia edema fluid protein The content is 0.1-0.9g/dl. The examination is usually used for chronic large and swollen limbs. It can be operated only by syringe and fine needle. The method is simple and convenient, but it can not understand the lesion and function of lymphatic vessels. It is a rough diagnosis method.

(b) lymphangiography

A lymphatic vessel puncture injection of contrast agent, a method of examining the morphology of the lymphatic system, is a specific auxiliary examination of lymphedema.

Indications

(1) Identification of lymphedema and venous edema.

(2) Identification of primary lymphedema and secondary lymphedema.

(3) Those who plan to undergo lymphatic-venous anastomosis.

2. Lymphatic angiography methods are mostly performed by direct lymphatic vessel puncture and injection. Firstly, Ivanslan is injected subcutaneously at the level of the first to fourth metatarsal bones. 25 to 0.5 ml for 3 to 5 minutes, the blue thin strip superficial lymph can be seen. Tube, under the local anesthesia, cut the skin to separate the superficial lymphatic vessels, and bypass a filament line at the proximal and distal ends to temporarily block the proximal end, so that the lymphatic fluid is retained, and the lymphatic vessels are pierced with a 27-30 needle. Inject 1% procaine a little to confirm that it is in the cavity and does not leak. Fix the needle and connect it to the syringe through a plastic tube. Ethiodol 12ml (ethylene iodide oil) is injected at a uniform rate of 0.1-0.2ml/min. After injection of 2ml, Ankle joint and pelvic radiograph, identify whether the contrast agent has extravasation and remove the mis-injection into the vein, take out the needle after the injection, ligature the lymphatic tube to prevent lymphatic leakage, suture the skin, and the angiogram includes: anterior and posterior position of the calf, before and after the thigh Position, from the groin to the anterior and posterior position of the first lumbar vertebrae, oblique or lateral position.

3. Abnormal manifestations of lymphangiography

(1) Primary lymphedema: lack of lymphatic valve or insufficiency, lymphatic distension and distortion.

(2) secondary lymphedema: middle lymphatic vessels, distal lymphatic vessels dilated, distorted, increased and irregular, lymph node filling defects in metastatic lymph nodes, worm-like edges.

(three) isotope lymphangiography

Because lymphangiography does not provide quantitative kinetic data on lymphatic function, nor does it provide a simple case of lymphatic drainage from different limb sites, a valuable static lymphatic system intraocular angiography (nuclear imaging) is currently underway. Inject 0.25ml (75MBq) of 99m sulphide sulphide gel into the subcutaneous tissue of the second toe of the two feet, and use the r camera to face the lower abdomen and groin area of the patient, respectively, at 1/2, 1, 2 and 3 hours. Static image scanning, respectively, calculate the isotope amount of inguinal lymph node uptake, and study the lymphatic function of chronic lymphedema with isotope imaging, suggesting that the degree of lymphatic regression of the affected limb is related to the severity of lymphedema, in severe lymphedema, isotope The uptake rate is almost zero, and the percentage of lymphatic reflux in venous venous edema is significantly increased, so it can be used for the differential diagnosis of lymphedema and venous edema. Its sensitivity for diagnosing lymphedema is 97%, and the specificity is 100%. Compared with lymphangiography, radionuclide imaging is simple and diagnostic, but it can not locate lymphatic vessels and lymph nodes. Lymphatic lymphatic surgery is still better X-ray contrast.

In addition, the newly developed vascular non-invasive detection technology also contributes to the identification of venous edema and lymphedema. As an outpatient screening method, it is both simple and convenient.

Diagnosis of lymphedema

Early changes in skin and subcutaneous tissue should be differentiated from other diseases:

1. Venous edema: more common in deep venous thrombosis of the lower extremity, with acute onset of sudden swelling of the unilateral limb, with skin color bruising, obvious tenderness in the gastrocnemius and thoracic triangle, superficial veins revealed its clinical features, edema of the foot Not obvious, lymphedema is slower onset, and it is more common to swollen the back of the foot.

2. Angioedema: Edema occurs in the stimulation of external allergic factors, rapid onset, rapid regression, intermittent episodes, and lymphedema tends to gradually increase.

3. Systemic diseases: hypoproteinemia, heart failure, kidney disease, cirrhosis, mucinous edema, etc. can produce lower extremity edema, generally bilateral symmetry, accompanied by the clinical manifestations of their respective primary diseases, usually A detailed medical history inquiry, careful physical examination and necessary laboratory tests can be identified.

4. Congenital arteriovenous fistula: congenital arteriovenous fistula can be manifested as limb edema, but the general limb length and circumference are larger than the healthy side, the skin temperature is increased, superficial varicose veins, local area can be heard and vascular murmur, peripheral vein The blood oxygen content is close to the arterial blood oxygen content, and all of the above are unique features.

5. Lipoma: A small number of lesions with a wide range of lipoma or adipose tissue hyperplasia can be confused with lymphedema, but most of the lipomas are limited growth, the course of disease is slow, the subcutaneous tissue is soft and edema, and soft tissue X-ray molybdenum is feasible if necessary. Target film to help diagnose.

Sometimes it is necessary to distinguish between scleroderma, certain circulatory disorders, cardiogenic, nephrogenic diseases, hypoproteinemia, and edema caused by infection or the use of drugs with sodium retention.

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