Anatomy, Lymphatic System


Article Author:
Manda Null


Article Editor:
Manuj Agarwal


Editors In Chief:
Susan Jeno
Sarah Fabiano


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Radia Jamil
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James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/22/2019 11:46:19 AM

Introduction

The anatomy of the lymphatic system closely parallels that of the peripheral vascular system. It functions by unilaterally returning lymphatic fluid to the vascular system where it is eliminated. Almost every organ in the body has lymphatics which generate a variety of byproducts that require elimination. Examples of organs in the body that contain lymphatic tissue include the gastrointestinal (GI) tract, spleen, lymph nodes, tonsils, and thymus. Lymph nodes function to monitor the composition of lymphatic fluid/blood, engulf any pathogens, augment an immune response, and eradicate infection. The thymus serves to mature and develop T cells in response to an inflammatory process, immune response or malignancy. The absorption and transport of fats and fat-soluble vitamins from the GI system also requires lymphatics. [1]

The lymphatic fluid is eventually emptied at the junction of the left subclavian vein and left internal jugular veins. Lymphatic fluid is derived from plasma. It leaks out of the capillary walls because of pressure exerted by the heart or osmotic pressure at the cellular level. As the interstitial fluid accumulates, it is picked by the tiny capillary lymphatics, passes through the lymph nodes, and finally returns the fluid to the venous circulation. As the lymph passes through the lymph nodes, both monocytes and lymphocytes enter it.

In the GI tract, the lymphatic fluid has a milk-like appearance that is chiefly due to the presence of cholesterol, glycerol, fatty acids and other fat products. The vessels that transport the lymphatic fluid from the GI tract are known as lacteals.

Lymphatic capillaries are very thin vessels which are blind-ended tubes. These lacteals have a thickness of a single cell, but the cells are arranged in an overlapping manner so that the fluid from the outside can enter it with relative ease. The lymphatic capillaries tend to form a large network of tubes that are known as lymphatic vessels.

The two major lymphatics of the body include the right lymphatic duct and the thoracic duct. The right duct drains most of the right upper quadrant whereas the thoracic duct drains the lower body including the extremities and abdomen. To ensure that fluid does not flow backward, all lymphatic have one-way valves. The forward flow of lymph is due to the pressure gradient created by the muscle contractions and respiratory movements.

The key feature of lymphatic vessels is that they have thin endothelial walls and have an overlapping arrangement. This morphology allows for any fluid from the tissues to enter the cells. The lymphatic capillaries eventually merge to form much a much bigger network of vessels that are located deep within the body. These lymphatic vessels eventually form the (1) right lymphatic duct and (2) the thoracic duct.

Function

The key functions of the lymphatics include the following:

  • Defend against foreign particles and microorganisms
  • Restore any excess protein molecules and interstitial fluid back to the systemic circulation
  • Absorption of fat-soluble vitamins and fatty substance from the gastrointestinal tract and transport them to the venous circulation

Issues of Concern

The Thoracic Duct

The thoracic duct is a thin-walled tubular vessel measuring 2 to 4 mm in diameter. The length of the duct ranges from 36 to 45 cm. The thoracic duct begins in the abdomen at the level of the second lumbar vertebrae. Initially, it is located on the right side and slightly posterior to the aorta and by the time it enters the right crus of the diaphragm, it is side by side with the aorta. It ascends in the thoracic cavity slightly anterior and to the right of the vertebral column. At the level of the fifth thoracic vertebrae, the thoracic duct crosses over to the left of the vertebral column. From here it ascends vertically and joins the junction of the left subclavian and left jugular vein the neck.

Clinically, if a patient has an injury to the thoracic duct below T5, then fluid will collect in only the right pleural cavity. But if the injury is to the thoracic duct above T5, then fluid will appear in both pleural cavities.

Injury to the thoracic duct in the neck area can be managed with drainage alone, but if the thoracic duct is damaged in the chest cavity, drainage and surgery are usually required. It is rare for the thoracic segment of the thoracic duct to seal on its own. [2][3][4]

Clinical Significance

Lymphatic leaks do occur when the vessels are damaged. In the abdomen, lymphatic damage may occur during surgery, especially during retroperitoneal procedures like repair of an abdominal aortic aneurysm. These leaks are mild, and the lymph fluid eventually gets absorbed by the vessels in the peritoneum and mesentery. When the thoracic duct is injured in the chest, the leak can be extensive. In the majority of cases, conservative care with a no-fat diet (medium chain triglycerides) or total parenteral nutrition is not successful. In most cases, if the injury to the thoracic duct was surgical, then a surgical procedure is required to tie off the duct. If the thoracic duct is injured in the neck, then insertion of a drainage tube and a low-fat diet will help seal the leak.

Other Issues

The lymphatic system is also prone to diseases like the venous and arterial circulation. A relatively common disorder of the lymphatic system is the development of lymphedema. When this occurs, the lymphatic system is unable to drain lymphatic fluid which results in accumulation of the fluid causing swelling of the extremity. Lymphedema is classified as primary or secondary.

Primary lymphedema is an inherited disorder where the lymphatics may be missing or poorly developed. This condition usually presents soon after birth or sometimes may present later in life. There are no great treatments for primary lymphedema. Surgery procedures of the past era were found to be mutilating and not done today. The present-day treatment revolved around the use of compression stockings, pumps, and constrictive garments. [5][6][7]

Secondary lymphedema is an acquired disorder that has many causes including cancer, infection, trauma or following a surgical procedure. The treatment depends on the cause. In most cases, if the inciting cause is removed, the drainage will resume. However, one may need to wear compressive stockings permanently in some cases. Physical therapy may help when the extremities are involved.

Lymphomas are malignancies that arise from the cells of the lymphatic system. There is usually malignant transformation of specific lymphocytes in the lymphatics or lymph nodes that are present in the gastrointestinal tract, neck, axilla or groin. Symptoms of lymphoma may include night sweats, fever, fatigue, itching and weight loss.

Cancers of a variety of organs may commonly spread to involve regional lymph nodes.

Lymphadenitis occurs when the lymph nodes become inflamed. The cause is usually an adjacent bacterial infection. The lymph nodes usually enlarge and become tender.

Filariasis is a very common disorder caused by a parasite in Africa. The parasite rapidly divided and obstructs the lymph nodes in the groin, making it difficult for the lymphatics to drain the extremity. This often results in huge extremities and marked disability.


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Anatomy, Lymphatic System - Questions

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Which is true about lymph nodes?



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The flow of a bacterium entering a lymph node via an afferent lymph vessel would initially be into which of the following regions?



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Where are the primary T-cells of a lymph node located?



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Which of the following groups of lymph nodes are just medial to the femoral vein and drain through the femoral canal?



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The largest lymph nodes by size have which of the following?



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Regarding axillary lymph nodes levels, which claim is true?



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Which of the following is not a lymphoid organ?



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Which of the following substances is not found in high concentrations in lymphatic fluid?



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A 52 year-old advertising executive, known to have had a bad duodenal ulcer for five years, is rushed to the hospital with massive vomiting of bright red blood. The patient had been "casually" following a regimen for peptic ulcer and had recently been under a "nervous strain." On admission to the hospital the patient reveals evidence of peritonitis, including absent bowel sounds and rigidity of the abdominal wall. Following appropriate supportive measures, including multiple blood transfusions, diagnostic studies are performed. It is ascertained that the patient most likely has a perforation of the first portion of the duodenum and surgery is performed. If biopsy reveals malignant cells in the region of the perforation, look for lymph node involvement in the area of the:



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The right lymphatic duct receives lymph from which one of the following?



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What group of lymph nodes is the first to receive the drainage from the tip of the tongue, lower central incisors and the middle portion of the lower lip?



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What is the name of the superficial group of lymph nodes that receives the major portion of the lymphatic drainage of the mandible?



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Which of the following is the least likely group of lymphatics to be involved from a subareolar carcinoma of the breast?



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A patient is complaining of an acutely tender swelling proximal and anterior to the medial epicondyle of the humerus. This proves to be an acutely inflamed epitrochlear (supratrochlear) lymph node. The primary infection was most likely:



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The lymphatics of the prostate do not drain directly into which of the following lymph nodes?



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Tumors of the testis tend to spread via the lymphatics. Where does the lymphatic drainage from the testes first pass?



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Anatomy, Lymphatic System - References

References

Granzow JW, Lymphedema surgery: the current state of the art. Clinical     [PubMed]
Ilahi M,Ilahi TB, Anatomy, Thorax, Thoracic Duct null. 2018 Jan     [PubMed]
Ohkura Y,Ueno M,Shindoh J,Iizuka T,Ka H,Udagawa H, Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy. Annals of surgical oncology. 2018 Jul 11     [PubMed]
Glatz T,Marjanovic G,Hoeppner J, [Prevention and Surgical Therapy of Chylothorax]. Zentralblatt fur Chirurgie. 2018 Jun     [PubMed]
Kilarski WW, Physiological Perspective on Therapies of Lymphatic Vessels. Advances in wound care. 2018 Jul 1     [PubMed]
Rooney L,Cooper-Stanton G,Cave-Senior J, Compression therapy and exercise: enhancing outcomes. British journal of community nursing. 2018 Jul 2     [PubMed]
Zemmez Y,Boui M, [Elephantiasis of the left lower limb]. The Pan African medical journal. 2018     [PubMed]

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