Lymphatic system
Dr hassan Brejiah
General surgeon
Lymphatic system
The lymphatic system is the system of vessels, cells, and organs
that carries excess fluids to the bloodstream and filters pathogens
from the blood.
Lymph passes through lymph nodes before it re-enters the venous
system, mainly through the thoracic duct.
Failure of this mechanism leads to the accumulation of protein-rich
oedema fluid in the tissues (lymphoedema )
Functions of The Lymphatic System
• Reabsorbs excess interstitial fluid:
• returns it to the venous circulation
• maintain blood volume levels
• prevent interstitial fluid levels from rising out of control.
• Transport dietary lipids:
• Lymphatic vessels transport lipids
• lipid-soluble vitamins (A, D, E, and K)
• drain into larger lymphatic vessels
• lymphocyte development, and the immune
response
Components of the Lymphatic System
Lymph -A fluid substance
Lymphatic Vessels(Lymph transporter)
Lymphatic Capillaries
Lymphatic Vessels
Lymphatic Trunks
Lymphatic Ducts
Lymph Nodes
Lymphatic Organs
Thymus
Spleen
Tonsils
Peyers patches …
Lymphatic cells
Lymphatic duct
Lymph delivered into one of two
large ducts
– Right lymphatic duct drains right
upper arm and right side of head and
thorax .
– Thoracic duct arises as cisterna
chyli; drains rest of body
• Each empties lymph into venous
circulation at junction of internal
jugular and subclavian veins on its
own side of bod
lymphoedema
- Due to impaired lymphatic drainage in the
presence of normal capillary function.
• Lymphoedema causes the accumulation of
protein rich fluid, subdermal fibrosis and
dermal thickening.
• Characteristically fluid is confined to the
epifascial space (skin and subcutaneous
tissues); muscle compartments are free of
oedema. It involves the foot, unlike other forms of
oedema. There may be a 'buffalo hump' on the
dorsum of the foot and the skin cannot be
pinched due to subcutaneous fibrosis.
Causes of lymphoedema
Primary : often familial condition is •Congenital < 1 year: sporadic,
estimated to affect 2% of the adult Milroy's disease
population and is caused by a •Onset 1-35 years: sporadic,
developmental failure in which the Meige's disease
lymphatics may be absent, •> 35 years: Tarda
hypoplastic, or varicose and dilated.
It is usually categorised by the age
of onset.
Secondary : More common •Bacterial/fungal/parasitic infection
This develops when the lymphatic (filariasis)
system is obstructed or obliterated . •Lymphatic malignancy
•Radiotherapy to lymph nodes
See later …. •Surgical resection of lymph nodes
•DVT
•Thrombophlebitis
Clinical feature :
Symptoms :
• Gradual painless swelling of one or both legs, commences distally
on the foot and extends proximally, usually only to the knee.
• First presentation because of acute cellulitis: usually recurrent
episodes.
Signs :
Unlike other types of oedema, lymphoedema
characteristically involves the foot, as opposed
to the lower calf and ankle. This is characterised
by:
• Infilling of the submalleolar depressions
• A ‘hump’ on the dorsum of the foot
• ‘Square’ toes due to confinement by
footwear; also, the skin on the dorsum of
the toes cannot be pinched owing to
subcutaneous fibrosis (Stemmer’s sign)
• Pit easily initially, but with time fibrosis
and dermal thickening prevent pitting.
• Chronic eczema, fungal infection of the
skin (dermatophytosis) and nails
(onychomycosis), fissuring, verrucae, and
papillae are frequently seen in advanced
conditions. Frank ulceration is unusual.
Investigation
Lymphoedema is essentially a clinical diagnosis and most patients require
no further investigation.
Management : Most (95%) of patients can be managed non-operatively
nonsurgical measures
• Feet elevation above the level of the hip, and avoid prolonged standing
• Intermittent pneumatic compression devices
• Graduated compression therapy, with pressure exceeding 50 mmHg at the ankle.
• Diuretics are of no value and are associated with side effects including electrolyte
disturbance. No other drugs are of proven benefit.
• If there is evidence of infection, i.e., cellulitis, antibiotics should be administered
based on the culture and sensitivity. Fungal infections should also be treated.
Surgery
Operations fall into two categories: bypass procedures and reduction
procedures. They are only rarely performed.
Secondary Lymphedema
• As mention before – more common than primary.
• Axillary node dissection leading to lymphedema of the arm is the most common
cause of secondary lymphedema in the United State.
• now will talk about filariasis :
• MC cause of lymphedema worldwide .
• Particularly prevalent in Africa, India and South America
• Viviparous nematode Wucheria bancrofti, whose only host is man, is
responsible for 90% of cases and is spread by the mosquito (Culex)
• Disease is associated with poor sanitation.
• Pathogenesis
• Parasite enters lymphatics from the blood and lodges in lymph nodes,
where it causes fibrosis and obstruction, due partly to direct physical damage
and partly to the immune response of the host .
• Proximal lymphatics become grossly dilated with adult parasites .
• The degree of edema is often massive elephantiasis .
Clinical Features-
• Acute: Fever, headache, malaise, inguinal and axillary lymphadenitis,
lymphangitis, cellulitis, abscess formation and ulceration, funiculo-epididymo-
orchitis.
• Chronic: Lymphedema of legs (arm, breast), hydrocele, abdominal
lymphatic varices, chyluria and lymphuria.
Diagnosis
• Microfilariae enter the blood at night and can be identified on a blood
smear, in a centrifuged specimen of urine or in lymph itself.
• A complement fixation test. is also available and is positive in present or
past infection. Eosinophilia is usually present.
Treatment
• Diethylcarbamazine destroys the parasites but does not reverse the
lymphatic changes.
• Once the infection has been cleared, treatment is as for primary
lymphoedema.
complications of Lymphedema
• Limb swelling: Cause discomfort and aching.
• Infections : Recurrent bacterial and fungal infections,
recurrent cellulitis or lymphangitis leading to skin thickening.
(MC particularly erysipelas (Acute Streptococcus bacterial
infection))
• Risk of malignancy: Lymphangiosarcoma (Stewart–Treves’
syndrome)
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