best practice for the management of lymphoedema ... - EWMA

ASSESSMENT
Chyluria: milky coloured urine due
to reflux of chyle (the fat-bearing
lymph that normally drains from
the intestine to the thoracic duct)
into the lymphatics of the urinary
system
Assessment
Effective assessment of a patient at risk of
or with possible lymphoedema will be
comprehensive, structured and ongoing.
Here, assessment has been divided into
medical assessment and lymphoedema
assessment, but the two may run in parallel
within the same healthcare setting.
MEDICAL ASSESSMENT
The medical assessment is used to diagnose
lymphoedema and to identify or exclude
other causes of swelling (Box 8). If the
patient presents to a primary care setting,
the general practitioner may choose to
conduct some initial screening investigations
to exclude other causes of swelling
before referring the patient for confirmation
of the diagnosis of lymphoedema. If the
patient presents to secondary/tertiary care,
assessment may be by a medical specialist.
Most cases of lymphoedema are
diagnosed on the basis of the medical
history and physical examination. The
choice of investigations used to elucidate
the cause of the swelling (Box 9) will
depend on the history, presentation and
examination of the patient.
Specialist investigations
In secondary/tertiary settings, specialist
investigations may be conducted. These
should be performed according to standardised
protocols to ensure reproducibility of
data. Investigations include:
■ ultrasound 25 – to assess tissue
characteristics, eg for skin thickening and
tissue fibrosis
■ colour Doppler ultrasound 26 – to exclude
deep vein thrombosis and evaluate
venous abnormalities
■ lymphoscintigraphy 27 (Figure 2) – to
identify lymphatic insufficiency in
patients where the cause of the swelling
is unclear, to differentiate lipoedema and
lymphoedema (Table 2, page 9), and to
ASSESSMENT
C
An accurate assessment is essential for the appropriate treatment of lymphoedema.
BOX 8 Differential diagnosis of lymphoedema
Unilateral limb swelling:
■ acute deep vein thrombosis
■ post-thrombotic syndrome
■ arthritis
■ Baker's cyst
■ presence/recurrence of carcinoma*
Symmetrical swelling:
■ congestive heart failure
■ chronic venous insufficiency
■ dependency or stasis oedema
■ renal dysfunction
■ hepatic dysfunction
■ hypoproteinaemia
■ hypothyroidism/myxoedema
■ drug induced (eg calcium channel blockers,
steroids, non-steroidal anti-inflammatories)
■ lipoedema
NB These conditions may co-exist with or cause
lymphoedema.
*Presence or recurrence of carcinoma requires direct
referral to the appropriate oncology service.
BOX 9 Screening investigations
Blood tests:
■ full blood count (FBC)
■ urea and electrolytes (U&Es)
■ thyroid function tests (TFTs)
■ liver function tests (LFTs)
■ plasma total protein and albumin
■ fasting glucose
■ erythrocyte sedimentation rate
(ESR)/C-reactive protein (CRP)
■ B-natriuretic peptide
Urine dipstick testing, including observation
for chyluria
Ultrasound
Chest X-ray
evaluate potential candidates for surgery.
Quantitative lymphoscintigraphy
(lymphoscintigraphic function test)
involves a dynamic (exercise) component
in addition to the static (resting) phase
and provides additional information on
lymphatic transportation
6 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA