Chapter 31: Lymphatic System

The two most important functions of this system are maintenance of fluid
balance in the internal environment and immunity.

Both are important functions.

A third, somewhat less important, function is the absorption of lipids

from digested food in the small intestine and its transport to the large
systemic veins.

-Overview of the lymphatic system

The importance is maintaining a balance of fluid in the internal

environment.

Plasma filters into interstitial spaces from blood flowing through

capillaries.

Most IF is absorbed by tissue cells or reabsorbed by the blood

before it flows out of the tissue.

A small percentage of IF remains behind.

If this continued, increased IF would cause massive edema

of the tissue.

The high fluid pressure from this edema could cause tissue
destruction or even death as normal functions
became disrupted.

Can be avoided by the presence of lymphatic vessels that

act as drains to collect the excess fluid and
return it to the venous blood just before it reaches the
heart.

Lymphatic system is a component of the circulatory system because it

consists of a moving fluid (lymph) derived from the blood and tissue
fluid and a group of vessels (lymphatics) that return the lymph to the
blood.

The lymphatic vessels that drain the peripheral areas of the blood
parallel the venous return.

Lymphoid tissue: a type of reticular tissue that contains lymphocytes

 and other defensive cells.

Example: Lymph nodes are located along the paths of the

collecting lymphatic vessels.

Isolated nodules of lymphatic tissue--aggregated lymphoid

nodules (Peyer patches) in the intestinal wall or the
nodules of the veriform appendix of the large
intestine.

Additional structures: tonsils, thymus, spleen, bone

marrow

Lymphatic vessels do not form a closed ring, or circuit, but begin in the
intercellular spaces of the soft tissues of the body.

-Lymph and interstitial fluid

Lymph--clear, watery-appearing fluid found in the lymphatic vessels.

Interstitial fluid (IF)--fills the spaces between the cells.

Both lymph and IF closely resemble blood plasma in composition.

Main difference--they contain a lower percentage of proteins

than does plasma.

Lymph is isotonic, almost identical in chemical composition to IF

when comparisons are made between the two fluids taken
from the same area of the body.

Average concentration of protein in lymph taken from the

thoracic duct is about twice that found in most IF samples.

The elevated protein level of thoracic duct lymph (a mixture of

lymph from all areas of the body) results from
protein-rich lymph flowing into the duct from the liver and
small intestine.

A little more than one half of the 2800-3000 mL total daily lymph
flowing through the thoracic duct is derived from these two
organs.

Loss of Lymphatic Fluid

Lymph does not clot

 If damage to the main lymphatic trunks in the thorax
occurs as a result of penetrating injury, the flow of
lymph must be stopped surgically or death
occurs.

It is impossible to maintain adequate plasma protein

concentration by dietary means if significant loss of lymph
continues over time.

As lymph is lost, rapid emaciation occurs, with a progressive and

eventually fatal decrease in total blood fat and protein
concentration.

-Lymphatic vessels

-Distribution of lymphatic vessels

Often called lymphatics--originate as microscopic blind-end

vessels called lymphatic capillaries.

The wall of each lymphatic capillary consists of a single layer of

flattened endothelial cells. Each blindly ending
capillary is attached to surrounding cells by tiny
connective tissue filaments.

Lymphatic networks are located in the interstitial spaces and are

widely distributed throughout the body.

Lymphatic and blood capillary networks lie side by side

but are always independent of each other.

Branches form to join larger branches, which merge to

form the main lymphatic trunks--the right
lymphatic duct and the thoracic duct.

Lymph from entire body except the right upper quadrant drains
eventually into the thoracic duct, which drains into the left
subclavian vein at the point where it joins the left
internal jugular vein.

Lymph from RUQ of the body empties into the right lymphatic
duct and then into the right subclavian vein.

This can vary among individuals.

 For example, most people have three separate
lymphatic ducts that drain into the right S/C
vein rather than a single right lymphatic duct.

Because most of the lymph of the body returns to the

bloodstream by the thoracic duct, this vessel is considerably
larger than the other main lymph channels, the right
lymphatic ducts, but is much smaller than the large veins.

Thoracic duct is 1-5 mm, about 40 cm in length.

Originates in the lumbar region of the abdominal cavity as

a dilated structure up to 15 mm in diameter

Cisterna chyli--where fatty lymph called chyle from the

intestinal tract collects.

Thoracic duct then ascends a curving pathway to the root

of the neck, where it joins the S/C vein.

-Structure of lymphatic vessels

Lymphatics resemble veins in structure with these exceptions:

Have thinner walls

Contain more valves

Contain lymph nodes located at certain intervals along

their course.

Lymphatic capillary wall is formed by a single layer of large but

very thin and flat endothelial cells.

Openings (clefts) between endothelial cells of lymphatic

capillary walls are small, they are larger than
those found in blood capillaries.

As lymph flows from the thin-walled capillaries into vessels with a

larger diameter (0.2-0.3 mm), the walls become thicker
and exhibit the three coats typical of arteries and veins.

One-way valves are extremely numerous in lymphatics of all

sizes and give the vessels a somewhat varicose and
beaded appearance.
 Valves are present every few millimeters in large lymphatics and
are even more numerous in the small vessels.

Experimental evidence suggest that most lymph vessels have

the capacity for repair or regeneration when damaged.

-Functions of lymphatic vessels

Lymphatics play a critical role in numerous interrelated

homeostatic mechanisms.

The high degree of permeability of the lymphatic capillary wall

permits very large molecules and particulate matter
to be removed from interstitial spaces.

Proteins that accumulate in the tissue spaces can return to blood

only by way of lymphatics.

Lacteals (lymphatic capillaries in the villi of the small intestine)

serve an important function in the absorption of fats and
other nutrients.

The milky lymph found in lacteals after digestion contains

1-2% fat and is called chyle. IF has much lower lipid
content than chyle.

-Circulation of lymph

-Origin of lymph

Water and solutes continually filter out of capillary blood into the
IF. To balance this outflow, fluid continually reenters blood
from the IF.

About 10% of the fluid that enters from blood capillaries is

picked up by lymphatic capillaries and eventually
released to the systemic blood.

Newer evidence has disproved the old idea that healthy blood
capillaries do not "leak" proteins.

Each day about 50% of the total blood proteins leak out of the
capillaries into the tissue fluid and return to the
blood by way of the lymphatic vessels.
 From lymphatic capillaries, lymph flows through progressively
larger lymphatic vessels to eventually reenter blood
at the junction of the internal jugular and S/C veins.

-The lymphatic pump

There is no muscular pumping organ connected with the

lymphatic vessels to force lymph onward as the heart
forces the blood.

Lymph moves slowly and steadily along in its vessels.

Flows through the thoracic duct and reenters the general

circulation at a rate of about 3 liters per day.

Occurs despite the fact that most of the flow is

against gravity

It moves through the system in the right direction

because of the large number of valves
that permit fluid flow only in the central
direction.

Activities that result in central movement, or flow, of lymph are

called lymphokinetic actions.

Flow of lymph--lymphokinesis.

X-ray films taken after radiopaque material is injected into the

lymphatics show that lymph pours into the central
veins most rapidly at peak of inspiration.

This method of visualizing lymphatic vessels--

lymphangiography.

The mechanism of inspiration, resulting from the descent of the

diaphragm, causes intraabdominal pressure to
increase as intrathoracic pressure decreases.

This causes pressure to increase in the abdominal portion

of the thoracic duct and decrease in the thoracic
portion.

The process of inspiring establishes a pressure gradient in

the thoracic duct that causes lymph to flow
-Structure of lymph nodes

Oval or bean-shaped structures.

Some small (1 mm) others are as a large as a lima bean (more

than 20 mm).

Each lymph node enclosed by a fibrous capsule.

Biological filter placed in the channel of several afferent

lymph vessels. Once lymph enters the node it “percolates”
slowly through the spaces known as sinuses before
draining into the single efferent exit vessels.

One-way valves in both the afferent and efferent vessels

keep lymph from flowing in one direction.

Fibrous septa, or trabeculae, extend from the covering

capsule toward the center of the node.

Cortical nodes within sinuses along the periphery of the node are
separated from each other by these connective tissue
trabeculae. Each nodule is composed of packed lymphocytes
that surround a less dense are called a germinal center.

When an infection is present, germinal centers form and the

node begins to release lymphocytes.

B lymphocytes (B cells) begin their final stages of

maturation within the less dense germinal center of the
nodule and then are pushed to the more densely packed
outer layers as they mature to become antibody-producing
plasma cells.

The center of a lymph node is composed of sinuses and

medullary cords.

Both are lined with reticuloendothelial cells capable

of phagocytosis.

-Locations of lymph nodes

Most lymph nodes occur in groups, or clusters, in certain areas.

Preauricular lymph nodes: located just in front of the ear;

 these nodes drain the superficial tissues and skin on the
lateral side of the head and face.

Submental group and submandibular group: in the floor of

the mouth; lymph from the nose, lips, teeth drains through
these nodes.

Superficial cervical lymph nodes: in the neck along the

sternocleidomastoid muscle, these nodes drain lymph
(which has already passed through other nodes) from the
head and neck.

Superficial cubital lymph nodes (supratrochlear lymph

nodes): located just above the bend of the elbow; lymph
from the forearm passes through these nodes

Axillary lymph nodes: 20-30 large nodes clustered deep

within the underarm and upper chest regions; lymph from
the arm and upper part of the thoracic wall, including the
breast, drains through these nodes

Iliac lymph nodes and inguinal lymph nodes: in the pelvis

and groin; lymph from the pelvic organs, legs, external
genitalia drains through these nodes.

-Functions of lymph nodes

Perform at least two distinct functions: defense and

hematopoiesis

-Defense functions: Filtration and phagocytosis

The structure of the sinus channels within the lymph flows

through them. This gives reticuloendothelial cells that line
the channels time to remove the microorganisms and other
injurious particles—soot, for example—from the lymph and
phagocytose them.

Lymph nodes physically stop particles from progressing

farther in the body—a process called mechanical filtration.

Also make use of biological processes such as phagocytosis

to destroy particles, biological filtration also occurs here.
 Sometimes hordes of microorganisms enter the nodes that
the phagocytes cannot destroy enough of them to prevent
injury to the node.

Infection of the node—adenitis.

Cancer cells often break away from a malignant

tumor and enter lymphatics, they travel to the lymph
nodes, where they may set up new growths and
block flow of lymph. This may leave too few channels
for lymph to return to the blood.

For example, if tumors block axillary node

channels, fluid accumulates in the interstitial
spaces of the arm, causing the arm to become
markedly swollen.

Even viruses such as HIV and other types of

pathogens can infect or infest lymph nodes.

-Hematopoiesis

Lymphoid tissue of lymph nodes serves as the site of the

final stages of maturation for some types of lymphocytes
and monocytes that have migrated from the bone marrow.

Small aggregates of diffuse lymphoid tissue and other

lymphatic cell types are found throughout the body—
especially in connective tissues and under mucous
membranes.

-Lymphatic drainage of the breast

Cancer of the breast is one of the most common forms of malignancy

in women.

Cancerous cells from a single “primary” tumor in the breast often

spread to other areas of the body through the lymphatic system.

Lymphedema after breast surgery

Surgical procedures called mastectomies—some or all breast

tissue is removed—sometimes performed to treat breast cancer.

Because cancer cells can spread so easily through the extensive

 network of lymphatic vessels associated with the breast, the
lymphatic vessels and their nodes are sometimes also removed.

Such procedures interfere with the normal flow of lymph fluid

from the arm.

When this happens, tissue fluid may accumulate in the arm

—resulting in swelling, or lymphedema.

Fortunately, adequate lymph drainage is almost always

restored by the reestablishment of new lymphatic vessels,
which grow back into the area.

Breast infections (mastitis) area also a serious health concern,

especially among women who are nursing infants.

Can also spread easily through lymphatic pathways

associated with the breast.

-Distribution of lymphatics in the breast

The breast—mammary gland and surrounding tissues—is drained

by the following two sets of lymphatic vessels:

1. Lymphatics that originate in and drain the skin over the

breast, with the exception of the areola and nipple
2. Lymphatics that originate in and drain the underlying
substance of the breast itself, as well as the skin of the areola
and nipple.

Superficial vessels that drain lymph from the skin and surface
areas of the breast converge to form a diffuse cutaneous
lymphatic plexus. Communication between the cutaneous plexus
and large lymphatics that drain the secretory tissues and ducts
of the breast occurs in the subareloar plexus located under the
areola surrounding the nipple.

Lymphatic anastomoses and breast cancer

Anastomoses occur between superficial lymphatics from

both breasts across the middle line.

Such communication can result in the spread of

cancerous cells in one breast to previously healthy
 tissue in the other breast.

Both superficial and deep lymphatic vessels also

communicate with lymphatics in the fascia of the pectoralis
major muscle.

Removal of a wide area of deep fascia is required in

surgical treatment of advanced or diffuse breast
malignancy (radical mastectomy).

Cancer cells from a breast tumor sometimes reach the

abdominal cavity because of lymphatic communication
through the upper part of the linea alba.

-Lymph nodes associated with the breast

More than 85% of the lymph from the breast enters the lymph
nodes of the axillary region

Most of the remainder enters lymph nodes along the lateral

edges of the sternum.

Several very large nodes in the axillary region are in actual

physical contact with an extension of breast tissue called an
axillary tail.

Because of the physical contact between these nodes and

breast tissue, cancerous and infectious cells may spread by
both lymphatic extension and contiguity of tissue.

Other nodes in the axilla or chest wall will enlarge and

swell after being “seeded” with malignant cells or bacteria
as lymph from a cancerous or infected breast flows
through them.

For example, interpectoral nodes found between the

pectoralis major and minor muscles often contain
metastases from mammary cancer.

A sentinel lymph node (SLN) is the first lymph node to which a

cancerous tumor can spread. When a tumor is detected, the
nearby SLN may be identified and examined in a biopsy to
determine whether cancer cells are present—mets.
-Tonsils

Masses of lymphoid cells—tonsils—are located in a protective ring

under the mucous membranes in the mouth and back of the throat.

Ring is called the pharyngeal lymphoid ring.

This ring helps protect against bacteria that may invade

tissues in the area around the openings between the nasal
and oral cavities.

The palatine tonsils are located on each side of the throat.

The pharyngeal tonsils—adenoids—when they become swollen, are

near the posterior opening of the nasal cavity.

The lingual tonsils—near the base of the tongue.

Tubal tonsils—located near the opening of the auditory (eustachian)

tube.

Each of these tonsils has deep recesses called tonsillar cysts that trap
bacteria and put them in close contact with cells of the immune
system.

Tonsils serve as the first line of defense from the exterior and are
subject to chronic infection—tonsillitis.

Sometimes removed surgically if antibiotic therapy is not

successful or if swelling impairs breathing (tonsillectomy)—no
longer routine treatment because of the critical immunological
role played by the lymphoid tissue.

-Thymus

-Location and appearance of the thymus

Intensive study and experimentation have identified the thymus

as a primary organ of the lymphatic system.

Unpaired organ consisting of two pyramidal lobes with delicate

and finely lobulated surfaces.

Located in the mediastinum, extending up into the neck as far as

the lower edge of the thyroid gland and inferiorly as far as the
fourth costal cartilage.
 Size of the thymus relative to the rest of the body is largest in a
child about 2 year old.

Absolute largest at puberty.

Gradually atrophies after until in advanced old age, it may

be largely replaced by fat.

Age 60, lymphoid tissue is about half its maximum size and
virtually gone by 80 or so.

Process of shrinkage of an organ—involution.

Pink grayish in early childhood but with advancing age becomes

yellowish as lymphoid tissue is replaced by fat.

-Structure of the thymus

Lobes of the thymus are subdivided into small lobules by

connective tissue septa that extend inward from a fibrous
covering capsule.

Each lobule is composed of a dense cellular cortex and an inner,

less dense medulla.

Both cortex and medulla are composed of lymphocytes in

an epithelial framework quite different from the supporting
connective tissue seen in other lymphoid organs.

-Function of the thymus

Before 1961 we had no clue what it did.

Dr. Jacques F. A. P. Miller removed the thymus gland from

newborn mice.

Found that it plays a critical role against infections

Performs at least two functions—serves as the final site of

lymphocyte development before birth (the fetal bone marrow
forms immature lymphocytes, which then move to the thymus).
Second, soon after birth the thymus begins secreting a group of
hormones and other regulators that enable lymphocytes to
develop into mature T cells. Only T cells that pass immunological
testing by lymphoid cells such as macrophages and dendritic
 cells—only about 5% of the cells that mature each day—are
released into the bloodstream.

Because T cells attack foreign or abnormal cells and also serve

as regulators of immune function, the thymus functions as an
important role of the immune mechanism. It is most active in
childhood.

-Spleen

-Location of the spleen

Left hypochondrium of the abdominopelvic cavity, directly below

the diaphragm. Just above most of the left kidney and the
descending colon and behind the fundus of the stomach.

It is common to find accessory spleens embedded in the double

fold of serous membrane that connects the spleen and stomach.

Often form from splenic stem cells released from the

spleen during even minor injuries to the spleen.

-Structure of the spleen

Roughly ovoid in shape.

Size varies in different individuals and in the same individual at

different times.

Example: It hypertrophies during infectious diseases and

atrophies in old age.

Splenomegaly: abnormal spleen enlargement

Infectious conditions such as scarlet fever, syphilis, typhoid

fever

Sometimes accompanies hypertension

Also accompanies some forms of hemolytic anemia in

which red blood cells appear to be broken apart at an
abnormally fast rate.

Surgical removal of the spleen often prevents death in

such cases.
 Surrounded by fibrous capsule with inward extensions that
roughly divide the organ into compartments.

Arteries leading into each compartment are surrounded by

dense masses of developing lymphocytes. Whitish
appearance—white pulp.

Red pulp, made up of a network of fine reticular fibers

submerged in blood that comes from the nearby arteries.

Supports cords of WBCs and related cells surrounded

by blood-filled sinusoids.

After passing through the reticular meshwork, blood

collected in various sinuses and then returns to the
heart through veins.

-Functions of the spleen

Defense: As blood passes through the sinusoids of the spleen,

macrophages lining these venous spaces remove
microorganisms from the blood and destroy them by
phagocytosis.

Tissue repair: Monocytes found in the cords of WBCs in red pulp

just under the spleen’s outer capsule are mobilized when
significant tissue damage occurs, such as in heart attack or
stroke.

Large number of monocytes migrate quickly to the injured

tissue and assist in health and repair.

Hematopoiesis: Nongranular leukocytes—monocytes and

lymphocytes—complete their development and become
activated in the spleen.

Before birth, RBCs are also formed in the spleen, but after
birth the spleen forms RBCs only in cases of extreme
hemolytic anemia.

Red blood cell destruction and platelet destruction: Macrophages

lining the spleen’s sinusoids remove worn-out red blood cells and
imperfect platelets from the blood and destroy them by
phagocytosis.
 They also break apart the Hgb molecules from the
destroyed RBCs and salvage their iron and globin content
by returning them to the bloodstream from storage in bone
marrow and liver.

Blood reservoir: At any given point the pulp of the spleen and its
venous sinuses contain a considerable amount of blood.

Continually moving through the spleen, blood can rapidly

be added back into the circulatory system from this
functional reservoir if needed.

Normal volume of about 350 mL is said to decrease by

about 200 mL in less than 1 minute after sympathetic
stimulation that produces marked constriction of its
smooth-muscle capsule.

Self-transfusion—example, response to the stress

imposed by hemorrhage

Spleen is a useful organ but not a vital one.

Dr. Charles Austin Doan in 1933—first splenectomy.

4 year old girl dying of hemolytic anemia.

Based on the fact that spleen destroys RBCs.

Child recovered—operation landmark.

If spleen is ruptured, it might be when ribs are broken and

pushed into the spleen, significant internal bleeding can
occur.

If blood loss is rapid and not stopped in time, death

could result.

Surgical repair or removal of the spleen can stop the

blood loss and save a life.

Disorders of the lymphatic system

Lymphedema—abnormal condition in which swelling of tissues in the

extremities occurs because of an obstruction of the lymphatics and
accumulation of lymph.
 Most common type—congenital—more often seen in females
between 15-25.

Obstruction can be in both lymphatic vessels and lymph nodes.

Swelling will be soft but then becomes firm, painful,

unresponsive to treatment.

Frequent infections, involving high fever and chills, may occur

with chronic lymphedema.

Diuretics to reduce swelling are effective, strict bed rest,

massage, elevation of involved extremities.

If edema is severe and unresponsive to these

treatments or infection occurs, mobility is
compromised, surgical removal of involved
subcutaneous tissue and fascia may be required.

Surgical shunting of superficial lymphatic drainage

into the deep lymphatic system have been tried.

Can be caused by small parasitic worms called filaria that

infest the lymph vessels.

Rare in North America and is more often seen in the

tropics.

The flow of lymph is blocked, causing edema in the

affected extremities that in severe cases become so
swollen they resemble an elephant’s limbs.

Elephantiasis: condition of being an elephant.

Chronic swelling, thickening of the

subcutaneous tissue, and frequent bouts of
infections are common.

Lymphangitis: acute inflammation of lymphatic vessels, stems from

invasion of an infectious organism.

Characterized by thin, red streaks extending from an infected

region toward the lymph nodes.

These also become enlarged, tender, reddened.

 Necrosis or tissue death, along with development of
abscess leading to suppurative lymphadenitis.

Commonly involved: groin, axilla, cervical regions.

Infectious agents may eventually spread to bloodstream,

causing septicemia and possible death—rare if antibiotic
treatment started.

Disorders associated with lymph nodes and other lymphatic organs

Tonsillitis

Tonsils, composed of lymphoid tissue, serve as the first line of

defense from exterior and subject to acute or chronic infection—
tonsillitis.

Fever, sore throat, difficulty swallowing are common s/s.

Enlarged pharyngeal tonsils (adenoids) may cause nasal

obstruction.

May extend to middle ear by way of auditory tubes, causing

acute otitis media and possible deafness if untreated.

Antibiotics are usually initiated after dx of tonsillitis.

If unsuccessful, and swelling has endangered airway and

breathing, a tonsillectomy, or surgical removal of tonsils
may be performed.

Lymphoma

Tumor of the cells of lymphoid tissue.

Often malignant, but in rare cases can be benign.

Usually originate in isolated lymph nodes but can involve

lymphoid tissue in the liver, spleen, GI tract.

Widespread is common because disease spreads from node to

node.

Exact cause of neoplasms is unknown.

Two categories of lymphoma: Hodgkin, non-Hodgkin

 Hodgkin: malignancy with uncertain etiology.

Possibly from pathogen-induced tumor of T cells, no

evidence to totally support.

Possibly exposure to chemicals or other

environmental hazards.

Usually painless, nontender enlarged lymph nodes of

the neck or axilla.

Soon others enlarge in the same manner.

If they involve trachea or esophagus, pressure

results in difficulty breathing or swallowing.

One of the most curable if detected early.

Lymphedema caused by blockage of lymph nodes may cause

enlargement of extremities.

Disease may obstruct flow into or out of the liver, leading to liver
enlargement and failure.

Anemia, leukocytosis, fever, weight loss as it progresses.

Hodgkin—potentially curable with radiation, if it has not spread

beyond the lymphatic system.

Chemo also used in more advanced cases.

Infection from both disease and treatment is common.

Non-Hodgkin—malignancy of lymphoid tissue.

Etiology uncertain, possibly from a virus.

Patients with immunodeficiencies such as AIDS often

develop this.

Manifestations similar to Hodgkin, usually more

generalized involvement of lymph nodes.

Central nervous system often involved.

 Radiation and chemo.

Question

1. Your patient, Courtney, has a very swollen right foot and leg but the
left are not swollen at all. This was diagnosed as elephantitis, a type of
lymphedema caused by a blockage from:
a. Arteries
b. Veins
c. Capillaries
d. Lymphatic vessels