Lipedema: Difference between revisions

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Estimates of the incidence of lipedema vary widely, and range as high as 11% of the post-puberty female population.  Even if the number were only 5%, that would mean more than 6 million women in the United States alone.
Estimates of the incidence of lipedema vary widely, and range as high as 11% of the post-puberty female population.  Even if the number were only 5%, that would mean more than 6 million women in the United States alone.
==Differentiating lipedema from other diseases==
Lipedema must be differentiated from other causes of [[lower limb]] [[edema]] like [[chronic venous insufficiency]], acute [[Deep vein thrombosis|deep venous thrombosis]], [[lymphatic filariasis]], [[myxedema]], [[cellulitis]] and causes of [[generalized edema]].
{| class="wikitable"
|-
! Diseases
! colspan="7" |Symptoms
! rowspan="2" | Signs
! rowspan="2" | Gold standard Investigation to diagnose
|-
!
!History
!Onset
!Pain
!Fever
!Laterality
!Scrotal swelling
!Symptoms of primary disease
|-
| Lymphatic filariasis
|
* History of living in endemic area or travelling to it
|Chronic
|<nowiki>+</nowiki>
| +
|Bilateral
| +
|<nowiki>-</nowiki>
|
* [[Hepatomegaly]]
* [[Lymphedema]]
* [[Elephantiasis]]
* [[Lymphangitis]]
* [[Hydrocele]]
* Scrotal [[elephantiasis]]
* [[Lymphadenopathy|Lymphadenopathies]]
* [[Rhonchi]] may be present in patients with Pulmonary tropical eosinophilia syndrome.
|
'''Preparing blood smears'''
* Thick smears
# Thick smears consist of a thick layer of dehemoglobinized (lysed) [[Red blood cell|red blood cells]] (RBCs). 
# Thick smears allow a more efficient detection of parasites (increased sensitivity).
* Thin smears consist of [[blood]] spread in a layer such that the thickness decrease.
'''By the ultrasound''', the following findings can be observed:
* Dilated lymphatic channels
* Living worms tend to be in motion which called "filarial dance" sign.
|-
| [[Chronic venous insufficiency]]
|
* History of untreated [[varicose veins]]
* Painful bilateral [[lower limb]] [[swelling]] that increases with standing and decreases by rest and [[leg]] elevation.
|Chronic
|<nowiki>+</nowiki>
| -
|Bilateral
| +
(If congenial)
| -
|
* Typical varicose veins
* [[Skin]] change distribution correlate with varicose veins sites in the medial side of [[ankle]] and [[leg]]
* Reduction of [[swelling]] with limb elevation.
|
* [[Duplex ultrasound]] will demonstrate typical findings of [[Venous insufficiency|venous valvular insufficiency]]
|-
|[[Deep venous thrombosis|Acute deep venous thrombosis]]
|
* History of prolonged recumbency
* Classic symptoms of [[DVT]] include acute unilateral [[swelling]], [[pain]], and [[erythema]] 
|Acute
| +
| -
|Unilateral
| -
|May be associated with primary disease mandates recumbency for long duration
|
* Dilated [[superficial veins]]
* Difference in [[Calf muscle|calf]] diameter is twice as likely to have [[DVT]](most impotant sign )<ref name="pmid16027455">{{cite journal| author=Goodacre S, Sutton AJ, Sampson FC| title=Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis. | journal=Ann Intern Med | year= 2005 | volume= 143 | issue= 2 | pages= 129-39 | pmid=16027455 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16027455  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16539361 Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213086 Review in: Evid Based Med. 2006 Apr;11(2):56]</ref>
* Calf pain on passive [[dorsiflexion]] of the [[foot]] ([[Homan's sign]]) isn't realiable sign.
|
* [[Compression ultrasonography]] (CUS) with [[Doppler ultrasound|doppler]] is the diagnostic test of choice
* [[D-dimer]] level is used for unprobable cases
|-
|[[Lipedema]]
|
* Family history especially in women; [[X-linked dominant]] or [[autosomal dominant]] condition.<ref name="pmid20358611">{{cite journal| author=Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S et al.| title=Lipedema: an inherited condition. | journal=Am J Med Genet A | year= 2010 | volume= 152A | issue= 4 | pages= 970-6 | pmid=20358611 | doi=10.1002/ajmg.a.33313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20358611  }}</ref>
* Abnormal deposition of fat and [[edema]] and [[easy bruising]].
|Chronic
| +
| -
|Bilateral
| -
|<nowiki>-</nowiki>
|
* Tender with palpation
* Negative '''Semmer sign''' to differentiate from lymphedema.<ref name="pmid23939641">{{cite journal| author=Trayes KP, Studdiford JS, Pickle S, Tully AS| title=Edema: diagnosis and management. | journal=Am Fam Physician | year= 2013 | volume= 88 | issue= 2 | pages= 102-10 | pmid=23939641 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23939641  }}</ref>
* Pinching the [[skin]] on the upper surface of the [[toes]]. If it is possible to grasp a thin fold of [[tissue]] then it is negative result.
* In a positive result, it is only possible to grasp a [[lump]] of [[tissue]].
|
* MRI offers strong qualitative and quantitative parameters in the diagnosis of [[lipedema]] <ref name="pmid9412843">{{cite journal| author=Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D| title=MRI and ultrasonographic findings in the investigation of lymphedema and lipedema. | journal=Int Surg | year= 1997 | volume= 82 | issue= 4 | pages= 411-6 | pmid=9412843 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9412843  }}</ref>
|-
|[[Myxedema]]
|
* History of untreated [[hypothyroidism]].
* Infiltration of the skin with [[Glycosaminoglycan|glycosaminoglycans]] with associated water retention.
|Chronic
| +
| -
|Bilateral
| -
| +
([[hypothyroidism]] )
|
* [[Pretibial myxedema]]
|
* [[Thyroid function tests|Thyroid function tests.]]
|-
|([[Cellulitis]]-[[Erysipelas|erysipelas-]]<nowiki/>[[skin abscess]])
|
* Acute painful [[swelling]]
* [[Fever]]
|Acute
| +
| +
|Unilateral
| -
| -
|
* [[Tenderness]], hotness, and may be fluctuation if [[abscess]] formed.
* [[Lymphangitis]] in nearby [[Lymph node|lymph nodes]].
* [[Toxemia]] and [[fever]] in severe cases.
* [[Cellulitis]] involves the deeper [[dermis]] and [[erysipelas]] involves the upper dermis.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }}</ref>
|
* Usually it doesn't need any laboratory tests to diagnose.<ref name="pmid27434444">{{cite journal| author=Raff AB, Kroshinsky D| title=Cellulitis: A Review. | journal=JAMA | year= 2016 | volume= 316 | issue= 3 | pages= 325-37 | pmid=27434444 | doi=10.1001/jama.2016.8825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27434444  }}</ref>
* [[Blood cultures]] are warranted for patients in the following circumstances:<ref name="pmid10834819">{{cite journal| author=Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY| title=Cellulitis complicating lymphoedema. | journal=Eur J Clin Microbiol Infect Dis | year= 2000 | volume= 19 | issue= 4 | pages= 294-7 | pmid=10834819 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10834819  }}</ref>
# [[Toxicity|Systemic toxicity]]
# Extensive [[skin]] or [[soft tissue]] involvement
# Underlying [[comorbidities]]
# persistent [[cellulitis]]
* In patients with recurrent [[cellulitis]], serologic ''testing for [[beta-hemolytic streptococci]]'' is a good diagnostic tool''.''<ref name="pmid4005155">{{cite journal| author=Leppard BJ, Seal DV, Colman G, Hallas G| title=The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. | journal=Br J Dermatol | year= 1985 | volume= 112 | issue= 5 | pages= 559-67 | pmid=4005155 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4005155  }}</ref>
|-
|Other causes of [[generalized edema]]
|
* History of chronic general condition (cardiac-liver-renal)
|Chronic
| -
| -
|Bilateral
| -
|<nowiki>+</nowiki>
|
|
* According to the primary cause ( Echo- [[LFTs]]- RFT)
|}


==Symptoms==
==Symptoms==

Revision as of 16:49, 27 July 2017

Lipedema is a disorder of adipose tissue distinguished by five characteristics: 1) it can be inherited; 2) it occurs almost exclusively in women; 3) it can occur in women of all sizes, from the anorexic to the morbidly obese; 3) it involves the excess deposit and expansion of fat cells in an unusual and particular pattern – bilateral, symmetrical and usually from the waist to a distinct line just above the ankles; and 4) unlike the “normal” fat of obesity, lipedemic fat cannot be lost through diet and exercise. Surgery is highly controversial, and in many cases, can make the condition worse.

Lipedema usually is triggered at puberty, but can trigger or worsen during or after pregnancy, at peri-menopause, and following gynecological surgery. If lipedema is diagnosed early, which currently is very rare, it is possible to prevent a significant expansion of lipedemic fat cells, and to alert patients to their heightened risk for obesity so they can take appropriate action.

Estimates of the incidence of lipedema vary widely, and range as high as 11% of the post-puberty female population. Even if the number were only 5%, that would mean more than 6 million women in the United States alone.

Differentiating lipedema from other diseases

Lipedema must be differentiated from other causes of lower limb edema like chronic venous insufficiency, acute deep venous thrombosis, lymphatic filariasis, myxedema, cellulitis and causes of generalized edema.

Diseases Symptoms Signs Gold standard Investigation to diagnose
History Onset Pain Fever Laterality Scrotal swelling Symptoms of primary disease
Lymphatic filariasis
  • History of living in endemic area or travelling to it
Chronic + + Bilateral + -

Preparing blood smears

  • Thick smears
  1. Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs).
  2. Thick smears allow a more efficient detection of parasites (increased sensitivity).
  • Thin smears consist of blood spread in a layer such that the thickness decrease.

By the ultrasound, the following findings can be observed:

  • Dilated lymphatic channels
  • Living worms tend to be in motion which called "filarial dance" sign.
Chronic venous insufficiency Chronic + - Bilateral +

(If congenial)

-
  • Typical varicose veins
  • Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg
  • Reduction of swelling with limb elevation.
Acute deep venous thrombosis Acute + - Unilateral - May be associated with primary disease mandates recumbency for long duration
Lipedema Chronic + - Bilateral - -
  • Tender with palpation
  • Negative Semmer sign to differentiate from lymphedema.[3]
  • Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result.
  • In a positive result, it is only possible to grasp a lump of tissue.
  • MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema [4]
Myxedema Chronic + - Bilateral - +

(hypothyroidism )

(Cellulitis-erysipelas-skin abscess) Acute + + Unilateral - -
  • Usually it doesn't need any laboratory tests to diagnose.[6]
  • Blood cultures are warranted for patients in the following circumstances:[7]
  1. Systemic toxicity
  2. Extensive skin or soft tissue involvement
  3. Underlying comorbidities
  4. persistent cellulitis
Other causes of generalized edema
  • History of chronic general condition (cardiac-liver-renal)
Chronic - - Bilateral - +
  • According to the primary cause ( Echo- LFTs- RFT)


Symptoms

Patients tend to gain weight in lipedemic areas and lose it in non-lipedemic areas. Obese lipedema patients who undergo bariatric surgery lose fat primarily from the waist up. Even anorexic women can starve and exercise away "normal" fat but retain lipedemic fat.

The classic early-stage lipedemic profile is a woman who looks like a size 8 from the waist up and a size 16 from the waist down with disproportionately large, column-like legs. As lipedema progresses, patients become increasingly heavy in the lower body. The additional, expanding fat cells interfere with the pathways of lymphatic vessels, and patients can develop secondary lymphedema, a condition known as lipo-lymphedema. Many lipedema patients cannot tolerate the compression garments associated with conventional lymphedema treatment because the underlying lipedemic fat is very painful, and those patients therefore are at risk for the side effects of uncontrolled lymphedema, including recurring blood infections and fibrosis.

Women with lipedema also are at very high risk for obesity because the lipedemic fat cannot be lost, and because as the condition worsens, patients become progressively less mobile.

Treatment

Treatment is designed primarily to address the secondary lymphedema part of the lipedema patient’s condition. This treatment includes a course of manual lymphatic drainage and bandaging by a lymphedema therapist, followed by the wearing of custom-fitted compression garments or devices - usually stockings and sometimes biker shorts. Compression prevents recurrence of lymphedema, and in some lipedema patients can reduce the pain of lipedemic fat.

There is no cure for lipedema.

History

Although first identified in the United States, at the Mayo Clinic in 1940, lipedema is barely known in that country – to physicians or to the patients who have the disease. Lipedema often is confused with obesity, and a significant number of patients currently diagnosed as obese are believed to have lipedema, either instead of or in addition to obesity.

Lipedema has multiple spellings. "Lipedema" is the American spelling, while "Lipoedema" is used in Britain and Europe. "Lipodema" is also used occasionally.

References

de:Lipödem

Template:WikiDoc Sources

  1. Goodacre S, Sutton AJ, Sampson FC (2005). "Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis". Ann Intern Med. 143 (2): 129–39. PMID 16027455. Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56
  2. Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). "Lipedema: an inherited condition". Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.
  3. Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.
  4. Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). "MRI and ultrasonographic findings in the investigation of lymphedema and lipedema". Int Surg. 82 (4): 411–6. PMID 9412843.
  5. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
  6. Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
  7. Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). "Cellulitis complicating lymphoedema". Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.
  8. Leppard BJ, Seal DV, Colman G, Hallas G (1985). "The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas". Br J Dermatol. 112 (5): 559–67. PMID 4005155.