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Disorder of
lymphokinesia in the
extremities
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Classification of diseases of lymph
system
Non-inflammatory diseases:
Lymphedema
Lymphangioma:
Capillary lymphangioma
cavernous lymphangioma
cystic lymphangioma
Inflammatory diseases:
lymphangitis
lymphadenitis
erysipelatous inflammation.
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Lymphedema
is a condition of increased mass of tissue
(skin, subcutaneous fat, connective tissue)
due to accumulation of fluid rich inproteins in the intercellular spaces and in
lymph viae, increased mass of keratinocytes,
fibroblasts, migrating immunocompetentcells and intercellular substance.
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Etiologicalclassification of
lymphedema
Primary:
aplasia of initial portion of lymph viae;
hypoplasia of lymph collectors;
atresia and agenesia of lymph collectors;
agenesia of lymph nodes; idiopathic fibrosis of inguinal lymph nodes.
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Etiologicalclassification of
lymphedema Secondary:
secondary congenital lymphedema - caused by loopsof the umbilical cord, amniotic constrictions, hair of
the foetus; malignant neoplasms;
iatrogenic lymphedema (after surgery or radiation
therapy);Trauma;
lymphangitis and lymphadenitis (bacterial, fungal, viral
or caused by chemical substances).
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Iatrogenic lymphedemadevelops due to
a diagnostic or therapeutic intervention
upon
treatment of malignant neoplasm accompanied by
lymphodissection;
reparative surgery on arteries accompanied bymassive damage of lymph collectors;
surgery for fascial bed syndrome;
intervention damaging lymph viae by medicalerror, for example after surgery for hernia,
varicose disease, excision of cellulocutaneous
flaps, on meniscus.
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Stages of lymphedema
latent, pre-clinical,
clinical stages:
stage I of lymphedema the welling is soft, a deep recessremains upon pressing it. Overnight the swelling
diminishes or goes away.
stage II - At this stage the swelling becomes dense due
to sclerotic changes; it does not leave a recess upon
compression. It is called irreversible because the edema
does not go down overnight.
Stage III is elephantiasis.
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Elephantiasis.
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The main signs of lymphedema are
as follows:
One extremity is affected in most cases. If bothextremities are affected, asymmetry of edema can benoted.
There are no pains.
In uncomplicated lymphedema ulcers do not develop.There is usually no change of colour in lymphedema.
Stemmers sign - the skin of dorsal phalangeal surface
thickens, it cannot be pinched (this is usually observedat stage II and III).
At advanced stages the skin thickens, deep folds withragged edge appear; hyperkeratosis and lichenification
are noted; multiple warts are possible.
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Indirect
lymphography Indirect lymphography
makes it possible to visualizelymph vessels of the skin.
Nonionic water solublecontrast agent is injectedsubcutaneously with aninfusion pump. The contrast
agent penetrates lymphvessels; lymph collectors canbe usually traced for 10-30centimeters. Due to back
flow of lymph the dilatedcutaneous lymph network iscontrasted. In proximalobstruction greatly dilatedlymph collectors are
visualized.
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Radionuclide lymphography
For functional appraisal of lymph system
quantitative isotope lymphography is used. This
method investigates the clearance of nuclear
tracer, the time of its penetration to lymph nodesand the amount of tracer absorbed. Besides,
lymph vessels and nodes of the investigated
body part are visualized.
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If the lymphedema is due to a malignant
process, the patient will display the
following:
fast augmentation of edema; bad pain;
edema worse on the thigh, and less pronounced
on the shin and foot; ulcers;
spacious lesions.
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Complicated lymphedema
In lymphedema the risk of mycosis
(dermatomycosis, onychomycosis) increases. If
interdigital spaces are affected, the risk of
erysipelas increases.
Erysipelas. This complication should be
differentiated from cancerous lymphangitis,
transitory aseptic dermatitis, thrombophlebitis.
The worst complication of lymphedema is
angiosarcoma (Stewart-Treves syndrome).
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Conservative treatment.
compression hosiery,
massage,
prolonged elevation of
the extremity, physiotherapy
(electrophoresis,
ultraviolet irradiation),
remedial gymnastics,
drug therapy.
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Drug therapy oflymphedema
1) tissue trophism (vitamins B, ascorbic acid,riboflavin);
2) peripheral circulation (No-spa, papaverine);
3) microcirculation (trental, solcoseryl, low-
molecular dextran);
4) angioprotectors (escusan);
5) vain and lymph tonics (troxevasin, detralex,
ginkor-fort); 6) anti-inflammatory drugs if indicated (ibuprofen,
voltaren and others);
7) drugs with hyaluronidase effect (lidase).
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Surgical treatment.
Two groups of surgical methods
can be distinguished: interventions aimed at improving lymph outflow
from the affected extremity;
removal of subcutaneous fat that has undergone
fibrous degradation.
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Removal of subcutaneous fat
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Lymphangioma
is a defect of development of
lymph vessels beginning in the
embryo and noticeale in early
childhood.
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Capillary lymphangioma
looks like smaller or bigger pale nodes with
vitreous humor. The skin in the area of
lymphangioma has an ornage-likeappearance. There are greater cavities in
some places, lined with endothelium and
containing lymph. Upon compressionlymphangioma collapses a bit.
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Cavernous lymphangioma
consists of irregular cavities lined with
endothelium and filled with lymph. It occurs on
shoulders and forearms; it can cause diffuse
disfiguring thickening of the extremity. The skinabove it is often red, thin, covered with
transparent vesicles. Going down the depth of
soft tissues, lymphangioma can affect musclesand bones. It grows slowly, collapse upon
compression and then refill with lymph again.
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Cystic lymphangioma
is a fluctuating elastic tumour
consisting of one or more cavities
filled with yellowish fluid. It islocalized in the armpit, more seldom
on the thigh or other portions of
extremities.
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