penyakit sistem lymphe

8/17/2019 Penyakit Sistem Lymphe

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Secondary Lymphedema

• Secondary lymphedema usually results from atrauma to the lymphatic system

• Surgery

•

adiation therapy• !umor compression"obstruction

• !raumatic in#ury

• $nfection

• Lymphoproliferative disease

• !umor"cancer involvement



What is the lymphatic system ?

• etrieves proteins filtered out of the circulatorysystem by capillaries and returns them to thevenous system for circulation

• !he lymphatic system originates as lymphcapillaries in the spaces between cells

• !he capillaries #oin to form larger vessels calledthe lymphatics



Lymphatic System %continued&

• !he lymphatics are #oined together by lymphnodes which act as filters and empty into theright lymphatic duct or the thoracic duct

• Lymphatics:

– smaller diameter and thinner walls than veins or

arteries

– contain valves li'e veins to assist with lymph flow

– also are aided by s'eletal muscle contractions and pulsatile movements of surrounding blood vessels

to assist with lymph flow



(ow does it occur ?

• )ecreased lymph flow from lymphatic damageresults in increased protein concentration in theinterstitial fluid

• With increased protein concentration, fluid isshifted into the interstitial space due to oncotic

pressure

• With fluid accumulation in the interstitial space,swelling"edema occurs in that body part



+anual

Lymphatic)rainage



(ow freuently does it occur ?

• -ffects . / of the 0S population – over 1million people – usually from breast cancertreatment

• Post2mastectomy: 1343 /

• Post2mastectomy with axillary lymph nodedissection and radiation therapy: 5645 /

• *urther increased with obesity and"or infection



(ow freuently does it occur ?

%continued&• +ay also see with:

• lymphoma

• prostate cancer

• melanoma

• (odg'in7s disease

• ovarian cancer

• 8ushing7s disease

• Systemic lupus erythmatosus

• 9ven more common in third world countriesdue to prevalence of parasitic infections



!ypes of lymphedema

• -cute:

• mild, transient form

• occurring within days of surgery

•resolving within first wee's

• Painful:

• occurs to ; wee's after surgery

• freuently associated with phlebitis or lymphangitis

• 9rysipeloid:

• occurs with chronic form after local trauma



!ypes of lymphedema

%continued&• 8hronic:

• more insidious and painless form

• occurs .6 to 1 months after surgery after gradual

development of fibrous tissues• )ependent:

• occurs with fluid overloading conditions such a renal

failure or cardiovascular diseases

• more involving dependent or inactive extremities



Physiologic cons!"ncs

#$o% ly%&h'%(

)ecreased

circulating blood

volume

)ecreased cardiac

output

)ecreased effective

arterial blood volume

$ncreased renin"

aldosterone"

angiotensin $$ levels

$ncreased plasma

volume with

increased transudate

$ncreased distal

tubular reabsorption

of <a with retention

of water and <a



What is seen clinically ?

• 9dema of the involved anatomy

• Pain can, but not always may be, present

• more common with infection

• 0sually no s'in ulcerations are seen• if present, more consistent with chronic venous

insufficiency

• $f erythema, must consider infection

• !hic'ening, hardening or =doughiness> of thesubcutaneous tissue

• Seldom are s'in changes seen



Lymphedema Location



-re diagnostic tools

appropriate ?• Lymphangiography has been used in past toevaluate, however:

• rarely is it reuired due to strong correlation with

history and exam for diagnosis

• anatomical information gained has no impact on

treatment

• can freuently exacerbate the condition

•

$f clinical suspicion, venogram or venousdoppler can rule out presence of thrombosis

• est tools remain detailed history and exam



What happens if not treated ?

• - cycle of fibrosis, stasis and proteinaccumulation begins with progression andworsening of edema

• $ncreased incidence of infection

• 9lephantiasis may develop in final stages

• $n severe cases, rare complication oflymphangiosarcoma may occur



When is treatment

appropriate ?• -LW-@S in the presence of painless swelling,

especially if greater than 1 cm

•

$f swelling occurs after the ; wee' periodfollowing completion of treatment

• -LW-@S with swelling in the months or yearsafter treatment, but first must rule out cancer

recurrence or metastatic disease



What are goals of treatment ?

• $mprove cosmesis

• Preserve s'in integrity

• Soften subcutaneous tissues

• -void infection or lymphangitis• )ecrease limb siAe

• -void contracture of the involved limb

•+ost importantly: patient and family education



What are treatment options ?

• +edications:

• -ntibiotics

– should always have on hand to begin treatment with

first signs of infection

– should cover Bram positive organisms with most

common pathogen Broup - Strep

• )iuretics

– can decrease water and sodium in the interstitial fluid,

but have no impact on protein status

– ris's usually outweigh benefits

• enAopyrones " 8oumarin

– stimulate proteolysis

– not available in 0nited States or *)- approved



What are treatment options ?

• +echanical interventions• elevation

• protection of limb

• manual lymph drainage"massage

• compression garments to reduce and control edema

• exercise, especially of distal musculature, to facilitate

lymph flow

•

Surgery: <ot curative – 9xcisional: 8harles " (omans procedure

• debul'ing of the area to remove excess tissue to

decrease volume

–

Physiological:• draina e of the area via l m h to l m h or l m h to



+anual Lymphatic )rainage



What types of compression are

available ?• 8ompression stoc'ing

• can be used for treatment and maintenance

• 1 pairs are appropriate to maximiAe hygiene

• last from to ; months

• can be difficult to don or doff and 'eep in position

• 8ompressive wrapping

• better flexibility for specific problem areas and for

specific patients

• patients and families can learn techniue

• allow greater activity level than pumps

• can be time consuming to don



-vailable compression

%continued&• 8ompression pumps

• not adeuate for primary therapy

• do not address proximal edema

• high cost with decreased compliance

• less convenient for associated exercise or mobility

• variable protocols dependent on brand and type but

ranges:

– single chamber"uniform"intermittent compression:

5C2;C mm (g

– multi2chamber"differential"seuential compression:

;C2.1C mm (g

•

eid sleeve – mar'ets as bein less ex ensive less cumbersome and



andages



8ompressive andages



8ompression Barments



Seuential, Pneumatic Pumps



$ntermittent 8ompression )evices

8ontraindications

– )eep vein thrombosis

– Local superficial infection

– 8ongestive heart failure

– -cute pulmonary edema

– )isplaced or acute fractures



S'in 8are and (ygiene

• Lymphedema increases ris' of s'in brea'down,infection, and delayed wound healing

• Proper s'in care

•

$nspection• Protection



!reatment Wor's



!erima Dasih



What can Physiatry provide for

treatment ?• 9ducation regarding factors contributing to

lymphedema and therefore increasedcompliance

• 9arly treatment for initial or recurrent infection

• 9mphasiAe proper care of the extremity

• )etermination of appropriate therapy and"or

long2term compression needs



What are measures to be ta'en

for protection ?• +a'e every attempt to avoid:

• cuts scratches insect bites

•

hangnails punctures burns• )o not irritate or handle these in#uries if

they occur

• <o blood pressures or venipunctures in

involved limb• Liberal use of moisturiAer to avoid dryness

or crac'ing



+easures to ta'e %continued&

• Wear protective garments for appropriate

activities:• gardening or pruning

• dishwashing

• ba'ing"coo'ing

• sewing

• $mmediate contact with physician if presence

of infection• 8arry heavy parcels or purses on the opposite

limb

• Sunscreen or long2sleeved garments for sun

ex osure



+easures to ta'e %continued&

• Eewelry should not be worn on affected limb

• $nsect repellent for high ris' exposure

• 0tiliAe electric raAor for shaving

• 8hec' water temperature with other limb orthermometer before immersion

• -void heavy lifting or repetitive movementswith involved limb

• -void tight2fitting garments to affected limb

• -void climate temperature extremes

penyakit sistem lymphe

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