Lymphoedema – The ‘Silent’ Chronic Disease Part 1

Steve Norton defines Lymphoedema as an abnormal accumulation of protein-rich fluid in the spaces between the cells (interstitium), which causes chronic inflammation and reactive fibrosis of the affected tissues.[1]

Statistics on lymphoedema are difficult to determine as reporting is lax and many cases are misdiagnosed.

• The US Department of Health and Human Services estimates that lymphoedema affects an estimated 100 million men, women, and children around the world including at least 3 million Americans.[2]

• Other researchers place the number at over 200 million people worldwide[3] and about 3 million in Germany

• There are no significant South African Lymphoedema statistics

Many patients are offered assurances that lymphoedema is a normal complication following malignant disease and, as medical studies devote little attention to diseases of the lymphatic system, doctors and students have little acquaintance of lymphoedema. In addition to serious impairment of the quality of life, it can often lead to the sufferer being unfit for work making lymphoedema not only a medical problem, but also a social and psychological issue. Lymphoedema should be classified as a chronic disease which, if left untreated, tends to progress. If chronic lymph stagnation is left untreated for a period of 18 years, it can lead to one of the most malignant neoplasms,  Angiosarcoma (Stewart-Treves syndrome).

The distribution and arrangement of lymph vessels resembles a drainage network with one-way traffic, that removes some of the tissue fluid and proteins. Like a special waste collection service it also removes other tissue waste such as metabolic and inflammatory products, bacteria and cell debris.

The tissue fluid is collected in lymph capillaries that are larger than blood vessels and located just beneath the skin. The lymph is transported away to pre-collectors then collectors, the actual transporting vessels (with valves) that flow in a definite direction.

The largest lymph vessels are called trunks an ducts. The Thoracic duct collects fluid from: left and right lower quadrants, left upper quadrant and the left side of the head and neck. The Right lymphatic duct collects fluid from the right upper quadrant and right head and neck. These provide two entry points into the venous system in the two

clavicular regions.

Arranged along the lymph tracts are lymph nodes that regulate the concentration of the lymph, production of lymphocytes (white blood cells). They serve as the filtering stations for noxious matter such as bacteria, toxins and dead cells.  The 600-700 lymph nodes in our bodies vary in shape and size and can be round or oval, 3 mm or 3 cm. At immunologically important points the lymph nodes are present in groups, e.g. at the roots of the extremities (axilla, groin) and on the side of the neck. Lymph nodes connected to the lymph vessels of particular regions are called regional lymph nodes, such as the axillary lymph nodes in the case of the arms.

Approximately 1-2 litres of lymph per day are supplied to the blood circulation. Like veins, lymph vessels have valves, but they have their own rhythmic peristaltic dynamics. The segment of a lymph vessel between two valves is called a lymphangion. The function of the lymphangions adjusts perfectly to the relevant requirements:

when the body is at rest the lymphatic flow is reduced, if the lymph-dependent load increases for any reason, the lymph time volume increases immediately.

In the formation of the various types of oedema we differentiate between three insufficiencies: dynamic, mechanical and combined.

• Dynamic insufficiency: the lymphatic system is healthy: however, such a large quantity of fluid is produced that the extreme Transport Capacity (TC) limit is reached. The result is oedema.

• Mechanical insufficiency: the lymph vessels are diseased. reducing the Transport Capacity so sharply that the lymph-dependent protein load cannot be removed resulting in oedema.

• When dynamic and mechanical insufficiencies occur simultaneously it results in combined insufficiency. This results in Transport Capacity reduction and increased Lymphatic Load.

Lymphoedema normally manifests as a skin-coloured, painless swelling. A distinction is drawn between (rare) primary forms of not yet completely explained origin, and secondary forms, e.g. following accidents, cancer (removal of tumours), operations etc.

Written by Carla Potgieter Medical Orthotist Prosthetist (SA) / CDT Therapist (Norton)

[1] Steve Norton 2004 Norton School of Lymphatic Tissues

[2] Living Well with Lymphedema by A. Ehrlich, A Vinjé-Harrewijn PT, CLT, and E. McMahon PhD. Lymph Notes 2005, page 13

[3] Textbook of Lymphology by M. Földi, E. Földi, and S. Kubik as quoted in a review written by Leo Clodius MD and published in Lymphology Volume 38, No 2, June, 2005.

 

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