Article on Swelling

This article was featured at "The Hook." I thought some of you might be interested in it. There is also some interesting issues and questions being raised in the comments section. It would be worth checking out.

DR. HOOK- Big head: Swelling of parts has many causes

by JOHN HONG, MD, published April 10, 2008

Ex-Governor Eliot Spitzer must have had a pretty big ego to think he could hire prostitutes and not get caught. Hello! But then again, it seems most powerful people get a swollen head and feel untouchable-- until they get a swollen lip when they get caught. Perhaps if the head did visibly swell up, it would keep people "in check" because it would be pretty unattractive.

Swelling, in medical terms, is called edema and occurs when fluid from the blood vessels leak into the soft tissues, such as into the legs, arms, lungs, and belly. Not sure what edema is like? Talk to a woman with PMS who's puffy all over-- and be sure to give her flowers.

Legs are the most likely place to have edema. People often complain their socks leave dents in their shins and calves, like a Tempur-Pedic mattress, a condition called "pitting edema." The edema can be uncomfortable from the tension. If the edema goes into the feet, wearing shoes can become difficult (yes, Imelda Marcos).

There are many causes of edema, but a big ego is not one of them. For the legs, poorly working veins are often the issue. If the blood doesn't go up the veins, the blood will pool in the legs and start to leak fluid. That's why folks with leg swelling often start the morning with thin legs-- lying in bed reduces the blood in the legs. Then being upright all day, gravity keeps blood down in the legs, and they begin to swell. In a worse-case scenario, a blood clot (DVT: deep venous thrombosis) backs up the pipes. A DVT usually causes fast edema and on one leg, and this requires immediate medical attention.

Poor lymphatics can lead to lymphedema. For example, a mastectomy with lymph node exploration can lead to permanent arm edema. Lymphedema (as well as edema due to thyroid disease) doesn't cause a pitting edema. (It's more of a Serta mattress.)

Salt! We all hear too much sodium (found in table salt) isn't good for us, and this is especially true for those with edema. If the kidneys can't excrete enough sodium, the pressure in the blood vessels pushes fluid into the soft tissue. It's like when I eat too many salty French fries on a hot day at an amusement park and my fingers swell up. Fluid depletion, like on a hot day in the park, can make the kidneys retain salt and water to worsen edema. Good working kidneys are important to prevent the body from swelling up like a sumo wrestler.

The heart pumps blood through the body-- and in particular to the kidneys-- for proper filtration. People with a weak heart, such as in congestive heart failure, can experience edema. If pulmonary edema occurs, the fluid in the lungs makes it hard to breathe, in particular when lying down, because blood pools in the lungs and they leak fluid. If it's bad enough, the person may have to sleep sitting up in a chair.

Cirrhosis of the liver can cause terrible edema throughout the body, but in particular the belly (ascites). The ascites often requires drainage via a needle. Also, protein levels can drop with cirrhosis, which leads to more edema.

Treatment for edema can be tricky. Compression stockings, exercise, and elevation of the legs might not create Betty Grable gams, but they can be pretty effective. Vascular surgeons can treat poorly working veins. Diuretics can help but also worsen edema depending on the underlying problem, so it's a balancing act.

For politicians with a big head, a little humble pie (minus any salt) might be the best treatment of all. Wouldn't that be swell?

Dr. Hook cracks a joke or two, but he's a renowned physician with a local practice. Email him with your questions.

This is bit of a refresher - but it's always good to keep a focus on the root of a problem if you are looking for solutions, so here it is again . . .

WHAT IS THE LYMPH SYSTEM

Many have never heard of the Lymphatic System, let alone Lymphedema. So before talking of Lymphedema we need to take a look at what the Lymph System is and how it works.

When we take a look at the body from the outside in, we have our skin, just below that is our layer of fat, and then under that is our Lymph System (comprised of lymph collectors/capillaries, vessels that lead to the deeper lymphatic vessels along which pathway are the lymph nodes), and this over lays our muscles. The blood capillary system comes into the area between the fat layer and the lymph capillaries and releases the nutrients to the skin and surface tissues of the body. It is a clear fluid including a lot of proteins. As the blood leaves, it takes back 90% of what it dropped off- most of the clear fluid and the smallest particles. The other 10% of clear fluid (with the larger particles of proteins/cell debris/medications we’ve taken/etc.) makes up the lymph fluid. The human body produces approximately 2 liters of lymph fluid every day.

The Lymph Nodes are the “garbage disposals” of the system that filter and breaks down all those particles, balancing the solid to liquid consistency. Also, they manufacture white blood cells for our immune system. The last tube of the lymph system goes up through the chest and dumps the lymph fluid into the blood system just above the heart. There the lymph fluid joins the blood, being further filtered through the liver and kidneys, and then passing out of the body through urine.

In brief, the Lymphatic System is a network of vessels, tissues, and organs in vertebrate animals that helps the body regulate fluid balance and fight infection.

Lymphedema is when an area of the body swells due to the collection of lymph fluid. This can be any part of the body: arm, foot, leg, breast, abdomen, head, face, chest wall, genitals…The lymph fluid builds up when the lymph system has in some way become impaired. Causes of an impaired Lymph System include:

• Treatment of lymph node removal and radiation for cancer: this reduces the amount of fluid the lymph system is able to transport per unit of time, and can lead to Lymphedema right away, or years down the road.
• Scar tissue from trauma or surgery: Trauma from injury or surgery if it blocks or affects the lymph flow.
• Congenital malformation: some people are born with a lymphatic system that was not developed fully. This can show up at birth, within the first year of life, in the teen years, or as an adult fallowing a somewhat minor injury.
• Venus insufficiency: if the veins are not returning the blood as efficiently as they should, then the blood system is not taking bake its 90% of the clear high protein fluid it releases to nourish the skin and surface tissues as the blood pools, and that means more than 10% is remaining for the lymph system to transport. The lymph system can step up to the plate for a while, even years, but over time it gets tired and gradually is unable to keep up. Veins can become stressed to insufficiency due to obesity, pregnancy, blood clots, or simple genetics.

The cause of the lymphedema, and other medical conditions the person may have, need to be taken into consideration during treatment, but the basic treatment is the same for all.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

Lymphadema Still Underdiagnosed

Here's an article that came out recently in the amednews.com - the newspaper for america's physicians. Hopefully this will alert some doctors to recognize lymphedema in their patients and to help them get proper care.

Lymphedema no longer rare, still underdiagnosed

Washington -- Trained in family practice medicine, Caroline Fife, MD, didn't know what she was getting into when she decided to begin treating people with lymphedema.

She was operating a wound clinic at Memorial Hermann-Texas Medical Center in Houston and was receiving calls from people seeking relief for their swollen limbs. They seemed to have nowhere else to go. So she thought, "How hard can it be? I know a lot about leg swelling."

"Never say that," she cautioned. About nine years ago, she hired a part-time therapist for the clinic. Within a year she had eight therapists. "Patients came out of the woodwork."

She's been treating patients with lymphedema ever since, and she's had to reach out to others to learn how best to do so. "I had one lecture on the lymphatic system in medical school. [Lymphedema] seemed so rare I thought I would never need to know about it."

"It's an ignored field of medicine," said Saskia Thiadens, RN, the executive director of the National Lymphedema Network, based in Oakland, Calif., which she founded 20 years ago. "I would say that of the majority of patients who go to see their primary care physicians, the chances that he or she will be diagnosed are pretty slim."

Many patients are misdiagnosed for years, said Andrea Cheville, MD, associate professor of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minn. When diagnosing a patient with a swollen leg, for example, physicians tend to think, "Is it the heart? Is there a blood clot? Is there a tumor in the abdomen? Often patients get an echocardiogram. They will get an ultrasound of their leg and a CT scan of the belly. If those are negative, many times they are told, 'Well, this is nothing that is going to kill you. Aren't you glad? Good-bye.' "

Yet it's not so unusual to see patients, both men and women, with swollen limbs caused by a slowdown in the lymphatic system, which serves as an extensive drainage network to maintain the proper body fluid levels and defend against infections.

The numbers of people affected by the condition are difficult to come by. Estimates range from 35% to 45% of women treated for breast cancer -- a large number in itself considering that about 2.4 million women alive today have had breast cancer, according to the Centers for Disease Control and Prevention. This population is more commonly affected, since lymph nodes may be removed during treatment, thus slowing the entire system.

The lymphedema network has had a patient questionnaire on its Web site since 2001. Respondents are about equally divided as to whether they have primary lymphedema, which is congenital; or secondary, which seems to be due to a trauma, such as surgery.

But even that distinction has blurred as researchers are beginning to understand that everyone's lymph system is not created equal, Dr. Fife said. One person may have a fantastic drainage system that can continue to function well despite a huge assault, such as a radical mastectomy. Another person's system may be less robust and be disrupted by a minor injury.

Regardless, any slowdown can lead to the pooling of lymph and its cargo of protein molecules, salts, glucose, urea and other substances. The system carries several liters of fluid a day. An obstruction could result in tremendous amounts of fluid building in the body.

Another consequence of obesity

The rise in obesity is also contributing to the numbers of lymphedema patients. Ten years ago Dr. Fife didn't have any patients who weighed 500 pounds. Now, 2% or more of her patients are at this weight or heavier.

Why morbid obesity leads to lymphedema is unknown, but one theory is that fat may block the system. "So as everyone gets fatter, we have more lymphedema," Dr. Fife said.

Once a swelling has occurred, avoiding any stress on that body part is essential for preventing recurrences. Patients who have had lymphedema should not have a blood pressure cuff wrapped around the affected limb, or have injections or blood draws, Thiadens said. Go to the opposite arm or the leg.

Although there is no cure, controlling the swelling is important. Swelling can become permanent and cause irreversible limb distortions. In addition, other skin conditions can develop, including cellulitis. Plus, the body's defenses are impaired. One of Dr. Fife's patients, for instance, reads meters for the gas company. While tramping through backyards all day, he is bitten by mosquitoes and fire ants, and those bites often lead to infections and hospitalizations.

Treatment for lymphedema is a gentle massaging technique, called manual lymphatic drainage, which encourages lymph flow. Once a limb is reduced to near-normal size, efforts switch to compression bandages and garments to keep the swelling down.

Although lymph flow maps, complete with roadblocks, have not been available for years -- an earlier mapping technique had been painful and dangerous and was abandoned -- promising research is under way at Baylor College of Medicine, Houston.

Fluorescent dye is injected just under the skin, picked up by the lymphatics and transported throughout the system, said Eva M. Sevick-Muraca, PhD, professor of radiology at Baylor and principal investigator for the study. Its path is illuminated by shining near-infrared light on the skin. The light can penetrate several centimeters of tissue.

The technique, developed with funds from the American Cancer Society and the National Institutes of Health, has been tested in a phase I trial with normal subjects because, "We don't even know what normal lymph flow looks like," Dr. Sevick-Muraca said.

Researchers are beginning to test the system on lymphedema patients, specifically attempting to determine if lymph flow is enhanced by massage. "We image before, during and after the massage and see if the lymph is being pushed into the correct nodal basin," she said.

By Susan J. Landers, AMNews staff, 2007.

ADDITIONAL INFORMATION:

Lymphedema alert

Certain factors can lead to the development of lymphedema and may provide alerts to the cause of swelling in the arms, legs or other body parts. No diagnostic tests are available, but risk factors include:

• Breast cancer, if the patient received radiation therapy or had lymph nodes removed. Radiation therapy to the underarm area after surgical removal of the lymph nodes. Having a larger number of lymph nodes removed increases risk.
• Surgical removal of the lymph nodes in the underarm, groin or pelvic region.
• Radiation therapy to the underarm, groin, pelvic or neck regions.
• Scar tissue in the lymphatic ducts or veins and under the collarbones, caused by surgery or radiation therapy.
• Cancer that has spread to lymph nodes in the neck, chest, underarm, pelvis or abdomen.
• Tumors growing in the pelvis or abdomen that involve or put pressure on the lymphatic vessels and/or the large lymphatic duct in the chest and block drainage.
• Having an inadequate diet or being overweight may delay recovery and increase the risk for lymphedema.

Source: National Cancer Institute

Lymphedema Causes

First of all it’s important to know that lymphedema is one of the most misdiagnosed diseases in our world today. Because other diseases such as chronic edema have similar symptoms, many of the people who suffer from lymphedema don’t even know it. So what can cause lymphedema?

Primary Lymphedema can develop at any stage during the patient’s life. It can be present at birth (milroy’s), develop at or around puberty (praecox) or even in adulthood (tarda). Each of these instances stem from unknown causes or have been associated with vascular anomalies. Some anomalies would be hemangioma, lymphangioma, Klippel Trenaury and Port Wine Stain. Because the causes of primary lymphedema are neither exact nor fully understood, diagnosing this disease is often delayed or overlooked in the patient’s life.

Secondary Lymphedema can occur as a result of many different things. It is also referred to as acquired lymphedema because there is an event that has caused the lymphatic vessels to be damaged or impaired or the lymph nodes to be removed. Some of the causes can be but are not limited to surgery for cancer, (breast, head and neck, prostate, gynecological, bladder or colon) radiation therapy, chronic venous insufficiency, filiarisis, cellulites/lymphangitis, abdominal surgeries, joint replacements, rheumatoid arthritis, vascular surgeries and even traumatic injuries. All of these causes can either appear immediately or weeks, months and even years later.

Any part of the body or limb(s) can develop lymphedema. Remember that it is a dysfunction in the lymphatic system so any part of the lymphatic system can experience these problems and result in localized lymphedema. Recognizing lymphedema in its early stages is the best way to manage and handle the issue before it gets out of hand. Early detection and treatment will improve both the prognosis and condition. Some symptoms to look out for are persistent swelling in any limb or area of the body, tight skin in a specific area, decreased flexibility in the wrist, ankle or hand, difficulty in wearing clothing in one area of the body. It is vitally important that if you experience any or all of these symptoms you seek expert medical advice immediately. It is also a great idea to get at least one other opinion.