Edema / Lymphedema / General Swelling

In people with cancer, swelling of the stomach or abdominal area can have a few different causes.

• Fluid may collect in the area of the body containing the abdominal organs. This fluid is called ascites. It may result from the tumor causing the body to produce more fluid, or the tumor may be blocking the normal flow of fluid through the lymph and other body systems. Ascites can make someone feel bloated, uncomfortable and short of breath. If this does not bother the patient, it can be left alone. If there is discomfort, then the fluid sometimes can be drained. The draining of ascites from the abdominal cavity is called paracentesis. At times, medications can help the body eliminate the fluid. The medications often are not that helpful, because it’s not that there is too much fluid in the body, rather it is just collecting in the wrong places.
   
• Sometimes the bowels do not empty well. Stool may build up and gas may cause bloating. This can be due to constipation from opioids, from a general slowing of the bowels due to weakness, or a blockage of the bowel due to a tumor. In all these cases the patient usually has symptoms of constipation. Constipation from medication or slowed bowels can be treated with laxatives.
   
• As some illnesses progress, there can be swelling under the skin and in other body tissues. This is called edema.

Sometimes the causes of swelling can be treated and swelling decreased. For example, bowel functioning may be improved if a blockage is removed. At other times the cause of the swelling can’t be treated and it’s best to treat the symptoms associated with it. For example, if the swelling is causing shortness of breath, there are medications to ease this.

Refractory edema in advanced metastatic cancer is one of the more challenging clinical problems. Diuretic therapy tends not to be particularly effective.

Occasionally, there may be contributing factors that can be fully or partially addressed. There may be inferior or superior vena cava obstruction by clot (for which anticoagulation may be a consideration), or tumour (which might be helped with corticosteroids, radiation, chemotherapy). It is worth reviewing the medications to see if edema is a potential adverse medication effect. There are case reports of opioids causing peripheral edema, which improved with switching opioids, and gabapentin and pregabalin are known to cause edema.

Extensive intrabdominal and pelvic disease may impair venous and lymphatic return from the legs. Hypoproteinemia can result in edema due to fluid shifts into extravascular space.

General measures to reduce edema include:

• Elevation. This is not as helpful in lymphedema caused by tumour, but is often recommended nonetheless.
• Activity/exercise if possible.
• Compression garments. Involves physiotherapy or occupational therapy to assess for this possible intervention. Although not always well tolerated, these devices may be helpful.
• Manual lymph drainage through massage. Massage therapists and physiotherapists who specialize in lymphedema management may be able to help with this intervention.
  

Further care includes:

Meticulous and gentle skin care. This includes keeping the skin clean and moisturized in order to minimize the risk of skin-barrier breakdown and the risk of infections.
Assessment and care to ensure safety and mobility. For example, if lower limbs are heavy, transfers may be very difficult. If lower limbs are “weeping,” the person may be at risk of slipping on wet floors.

There are reports of using subcutaneous drainage for refractory lymphedema.[1,2] Subcutaneous drainage is assessed and considered on a case-by-case basis, and further research is required in this area.

References

1. Faily J, De Kock I, Mirhosseini M, Fainsinger R. The use of subcutaneous drainage for the management of lower extremity edema in cancer patients. J Palliat Care. 2007;23:185-187.

2. Jacobsen J, Blinderman CD. Subcutaneous lymphatic drainage (lymphcentesis) for palliation of severe refractory lymphedema in cancer patients. J Pain Symptom Manage. 2011;41(6):1094-1097.

Other references

CarePartners Palliative Care. Lower extremity lymphedema management toolkit. Author: April 2008.

Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema. J Am Acad Dermatol. 2008;59(2):324-331.