Recorded Lecture: Lymphatic System

What is lymph, lymphatic organs, and major lymph nodes?

• Lymph - portion of interstitial fluid that enters the lymphatic system

• Lymphatic organs - nodes, tonsils, thymus, spleen, thoracic duct, bone marrow

• Major lymph nodes - submaxillary, cervical, axillary, iliac, mesenteric, inguinal, popliteal, cubital, supraclavicular, parasternal

What are the two functions of the lymphatic system?

1. Immunity - protect body from illness/infection

2. Drain lymph (fluid) and push it back into bloodstream

What is the flow of lymph? Mneumonic?

“CVNTD”

1. Lymphatic Capillaries

2. Lymphatic collecting Vessels

3. Nodes - filter the lymph, along the length of the vessels

4. Lymphatic Trunks

5. Lymphatic collecting Ducts

6. Subclavian veins

Where does lymph drain?

• “RUL” Right upper quadrant (right side of face, UE drains into the Lymphatic duct)

• Rest of body drains into thoracic duct

What is lymphatic load?

Amount of lymphatic fluid transported

What is transport capacity?

Maximum amount of fluid that lymphatic system can transport

What is lymphedema? How does lymphedema happen?

• Lymphedema - chronic disorder characterized by an abnormal accumulation of lymph fluid in the tissues of one or more body regions

• Lymphatic load > transport capacity = lymphedema (too much load, not enough being transported, nowhere for it to go → fluid overload)

How does venous insufficiency and lymph node removal affect lymphatic load/transport capacity?

• Venous insufficiency → venous pooling → increases lymphatic load

• Lymph node removal → decreases transport capacity

What is primary vs. secondary lymphedema?

• Primary - congenital/genetic/hereditary abnormalities

  • Congenital lymphedema: Milroy disease

    • 0-2y, bilateral, LE, rare

  • Lymphedema Praecox: Meige disease

    • 9-25y, bilateral

  • Lymphedema Tarda: 35+y, UNIlateral, late onset

• Secondary - injury to one or more components

  • Lymph node removal

  • Infection

  • Tumor

  • Tramua

  • Chronic venous insufficiency - inc load

  • Fibrosis - dec capacity

  • Filariasis - parasite w. bancroffti/elephant leg

What are the 3 severity stage of lymphedema?

1. Pitting - pressure causes indentation of skin for several seconds after pressure is removed, significant but short duration edema w/ little/no fibrotic changes

2. Brawny - pressure feels hard w/ palpation, severe form of interstitial swelling w/ progressive, fibrotic changes

3. Weeping - most severe and long duration, fluid leaks from cuts/sores, wound healing significantly impaired, usually LE

What is a positive Stemmer’s sign? What does this indicate?

• Pinch skin on dorals surface of fingers/toes → cannot be lifted/difficult to pinch compared to uninvolved limb

• Indicative of worsening condition and stage 2/3 lymphedema

What are the stages of lymphedema?

• Stage 0 (latency)

  • No clinical edema, occasional reports of heaviness

  • Stemmer’s sign negative

  • Tissue & skin normal

• Stage 1 (reversible stage)

  • Edema present (soft and pitting)

  • Edema increases with standing and activity but reduces on elevation → intervention

  • Stemmer’s sign negative

• Stage 2 (spontaneously irreversible)

  • Hard swelling present; progresses to non-pitting “brawny” edema

  • Stemmer’s sign positive (may be negative early stage 2)

  • Tissue appears fibrosclerotic; proliferation of adipose tissue

• Stage 3 (lymphostatic elephantiasis)

  • Edema present; severe “brawny” nonpitting edema

  • Stemmer’s sign positive

  • Skin changes (papillomas, deep skinfold, warty protrusions, hyperkeratosis, mycotic infections) - can be weeping

  • Repeated bacterial and viral infections

What is the grading of pitting edema?

(stage 1/early stage 2 lymphedema, not as bad as brawny)

• 1+ = Mild, barely perceptible indentation; <1/4in pitting

• 2+ = Moderate, easily identified depression, return to normal within 15sec; 1/4in-1/2in pitting

• 3+ = Severe, depression takes 15-30sec to rebound; 1/2in-1in pitting

• 4+ = Very severe, depression lasts for >30sec or more; >1in pitting

What would indicate initial development of lymphedema in a patient post radical mastectomy w/ axillary node removal?

Decreased ROM of the fingers