LYMPAHTIC SYSTEM

LYMPH, LYMPHATICS AND ORGANS

LYMPHATIC SYSTEM
The lymphatic system, consisting of lymphatic vessels and various lymphoid tissues and organs, helps maintain fluid balance in tissues and absorb fats from the gastrointestinal tract. It also is part of the bodys defense system against disease. The lymphatic system is closely related to the circulatory system, both structurally and functionally. A network of lymphatic vessels drains excess interstitial fluid (the approximate 15% that has not been returned directly to the capillaries) and returns it to the bloodstream in a one-way flow that moves slowly toward the subclavian veins. Additionally, the lymphatic system functions in fat absorption and in the bodys defense against microorganisms and other foreign substances. In short, the lymphatic system has three principal functions. It transports excess interstitial (tissue) fluid, which was initially formed as a blood filtrate, back to the blood. It serves as the route by which absorbed fats and some vitamins are transported from the small intestine to the blood. Its cells (called lymphocytes), located in lymphatic tissues, help provide immunological defenses against disease causing agents.

FIGURE: The schematic relationship between the circulatory & lymphatic systems.
Interstitial (tissue) fluid is an extract of blood plasma formed at the pulmonary & systemic capillary networks. Lymph is the interstitial fluid that enters the lymphatic capillaries to be transported by lymphatic vessels to the venous bloodstream.

LYMPH AND LYMPHATIC VESSELS The lymphatic network of vessels begins with the microscopic lymphatic capillaries. Lymphatic capillaries are closed-ended most tissues. Within the villi of the small intestine, for example, lymphatic capillaries called lacteals, transport the products of fat absorption away from the GI tract. Because the walls of lymphatic capillaries are composed of endothelial cells with porous junctions, interstitial fluid, proteins, microorganisms, and absorbed fats (in the small intestine) can easily enter. Once fluid enters the lymphatic capillaries, it is referred to as lymph. Adequate lymphatic drainage is needed to prevent the accumulation of interstitial fluid, a condition called edema. From merging lymphatic capillaries, the lymph is carried into larger lymphatic vessels called lymph ducts. The walls of lymph ducts are much like those of veins. They have the same three layers and also contain valves to prevent backflow. The pressure that keeps the lymph moving comes from the massaging action produced by skeletal muscle contractions and intestinal movements, and from peristaltic contractions

of some lymphatic vessels. The valves keep the lymph moving in one direction.

FIGURE: A Photomicrograph of valve (arrow) within a lymph vessel. Interconnecting lymph ducts eventually empty into one of the two principal vessels: the thoracic duct and the right lymphatic duct. The larger thoracic duct drains lymph from the lower extremities, abdomen, left thoracic region, left upper extremity, and left side of the head and neck. The main trunk of this vessel ascends along the spinal column and drains into the left subclavian vein. In the abdominal area, there is a saclike enlargement of the thoracic duct called the cisterna chyli, which collects lymph from the lower extremities and the intestinal region. The smaller right lymphatic duct drains lymphatic vessels from the right upper extremity, right thoracic region, and right side of the head and neck. The right lymphatic duct empties into the right subclavian vein near the internal jugular vein.

FIGURE: The Lymphatic system showing the principal lymph nodes and other lymphoid organs. Lymph from the upper right extremity. The right side of the head and neck, and the right thoracic region drains through the right lymphatic duct into the right subclavian vein. Lymph from the remainder of the body drains through the thoracic duct into the left subclavian vein.

LYMPH NODES

FIGURE: The Structure of a Lymph node. (a) A photograph of a lymph node positioned
near a blood vessel, (b) a diagram of a sectioned lymph node and associated vessels and (c) a photomicrograph of a lymph node.

Lymph filters through the reticular tissue of hundreds of lymph nodes clustered along the lymphatic vessels. The reticular tissue contains phagocytic cells that help purify the fluid. Lymph nodes are small beanshaped bodies enclosed within fibrous connective tissue capsules. Specialized connective tissue bands called trabeculae divide the node. Afferent lymphatic vessels carry lymph into the node, where it is circulated through the sinuses, a series of irregular channels. Lymph leaves the node through the efferent lymphatic vessel, which emerges from the hiluma depression on the concave side of the node. Lymphatic nodules within the node are the sites of lymphocyte production, and are thus important in the development of an immune response. Lymph nodes usually occur in clusters in specific regions of the body. Some of the principal groups of lymph nodes are the popliteal and inguinal nodes of the lower extremity, the lumbar nodes of the pelvic region, the cubital and axillary nodes of the upper extremity, the thoracic nodes of the chest, and the cervical nodes of the neck. The sub mucosa of the small intestine contains numerous scattered lymphocytes and lymphatic nodules, and larger clusters of lymphatic tissue called mesenteric (Peyers) patches. OTHER LYMPHOID ORGANS In addition to the lymph nodes just described, the tonsils, spleen, and thymus are lymphoid organs. TONSILS The tonsils form a protective ring of lymphatic tissue around the openings between the nasal and oral cavities and the pharynx. SPLEEN The spleen is located on the left side of the abdominal cavity, to the left of the stomach from which it is suspended. The spleen is not a vital organ in an adult, but it does assist other body organs in producing lymphocytes, filtering the blood, and destroying old erythrocytes. In an infant, the spleen is an important site for the production of erythrocytes. In an adult, it contains red pulp, which serves to destroy old erythrocytes,

and white pulp, which contains germinal centers for the production of lymphocytes. THYMUS The thymus is located in the anterior thorax, deep to the manubrium of the sternum. Because it regresses in size during puberty, it is much larger in a fetus and child than in an adult. The thymus plays a key role in the immune system.

FIGURE: The structure of the spleen (a) A medial view, (b) A diagram of the pulp, and
(c) a photomicrograph (10x)

FIGURE: The Thymus is located in the mediastinum, medial to the lungs. The lymphoid organs are summarized in table below. LYMPHOID ORGANS ORGAN Lymph Nodes LOCATION In clusters or chains along the paths of larger lymphatic vessels FUNCTION Sites of lymphocyte production; house T lymphocytes and B lymphocytes that are responsible for immunity; phagocytes filter foreign particles and cellular debris from lymph. Protect against invasion of foreign substances that are ingested or inhaled. Serves as blood reservoir; phagocytes filter foreign particles, cellular debris, and worn

Tonsils

In a ring at the junction of the oral cavity and pharynx In upper left portion of abdominal cavity, beneath the diaphragm

Spleen

and suspended from the stomach Thymus Within the mediastinum, behind the manubrium

erythrocytes from the blood; houses lymphocytes Important site of immunity in a child; houses lymphocytes; changes undifferentiated lymphocytes into T lymphocytes

THORACIC DUCT
DEFINITION: It is the largest and elongated common lymphatic channel, conveys lymph from the whole part of the body into the blood stream except the Right Right Right Right Right Right Right Right side of head and neck. side of the face. superior extremity side of chest wall lung and Pleura of the heart and pericardium dome of the diaphragm surface of the liver

LENGTH: 38 to 45 cm BREADTH: 0.5 CM ( at its origin) BEGINNING: Thoracic duct starts as an upward continuation of cisterna chyle, which is situated infront of the bodies of L1 & L2 vertebrae. Vertebral Level At the lower border of T12 vertebrae. END: It ends in the left Brachiocephalic vein at the site of its formation, behind the left sterno clavicular joint. VARIATIONS IN TERMINATION:

1) Sometimes thoracic duct divides into a number of new vessels which ends separately into the left internal jugular and left subclavian veins. 2) Occasionally, the duct divides in the mid thoracic region where the right duct opens at the junction of right internal jugular and right subclavian veins after joining with the right lymphatic duct and left duct ends at the junction of left internal jugular and left subclavian vein. 3) The duct may terminate into either of the great veins. COURSE 1) After its origin, it enters into the thorax through the aortic opening of the diaphragm. 2) Then, it ascends upwards behind the oesophagus in the posterior mediastinum of the thorax. 3) At the level of T5 vertebra the duct inclines to the left. 4) Then, it further ascends upwards through the superior mediastinum along the left margin of the oesophagus. 5) At the root of the neck the duct arches laterally opposite the transverse process of C7 vertebrae. 6) Finally, the duct turns downwards to terminate usually, at the junction of left internal jugular vein and left subclavian vein. CHARACTERISTICS OF THE THORACIC DUCT I. It is flexible in character. II. Beaded in appearance. III. It has many valves on those sides which are exposed to pressure. RELATIONS 1. AT THE AORTIC OPENING: INFRONT Median Arcuate ligament. BEHIND TV 12 ON THE RIGHT Azygos vein ON THE LEFT Aorta 2. IN THE POSTERIOR MEDIASTINUM INFRONT Posterior sloping surface of the diaphragm

 1) 2) 3) 4)

Oesophagus Right pleural recess.

BEHIND T5 to T12 vertebrae with their intervertebral discs and anterior longitudinal ligament. Terminal parts of accessory Azygos and Hemiazygos veins. Right posterior intercostal arteries.

ON THE RIGHT SIDE Azygos vein Right Splanchnic nerves Right Sympathetic trunk Right Lung and Pleura

ON THE LEFT SIDE 1) Descending thoracic aorta. 2) Hemiazygos vein 3) Left Splanchnic Nerves 3. IN THE SUPERIOR MEDIASTINUM INFRONT 1) Arch of Aorta 2) Left subclavian artery BEHIND T1 to T4 vertebrae with intervertebral discs and anterior longitudinal ligament. ON THE RIGHT SIDE - Oesophagus ON THE LEFT SIDE Left lung and pleura 4. AT THE ROOT OF THE NECK INFRONT Left carotid sheath containing Left internal jugular vein, Left common carotid artery, Left vagus nerve. (Artery medially, vein laterally and nerve between and behind them) BEHIND a. Left sympathetic trunk with inferior cervical ganglion. b. Vertebral artery and vein c. Thyro cervical trunk and its branches. i. Inferior thyroid artery.

ii.Transverse cervical artery. iii.Suprascapular artery. d. Left phrenic nerve e. Left Scalenus anterior muscle f. Left subclavian artery (1st part) TRIBUTARIES 1) Confluence of lymph trunk (Cisterna Chyle) 2) Descending thoracic lymph trunks from the lower 6 or 7 intercostal spaces of both sides. 3) Ascending lumbar lymph trunks from the upper lateral aortic lymph nodes. 4) Upper intercostal trunks from upper 5 or 6 left intercostal spaces. 5) Mediastinal trunks from the convex diaphragmatic aspect of the liver, the pericardium, heart and oesophagus. 6) Left subclavian trunk (usually) but may drain into the left subclavian vein. 7) Left Jugular trunk (usually) but may drain into the left internal jugular vein. 8) Left broncho mediastinal trunk (occasionally).

FIGURE: The course of the thoracic duct.

LYMPHATIC DRAINAGE OF BREAST

INTRODUCTION: Lymphatic drainage of the mammary gland are divided into 3 ways. They are I. Lymphatics of the parenchyma of the breast and also from the skin of the Nipple and Areola. II. From the skin except Nipple and the Areola. III. From the Stroma I. LYMPHATICS OF THE PARENCHYMA OF THE BREAST AND ALSO FROM THE SKIN OF THE NIPPLE & THE AREOLA:
1. These originate in a plexiform network from the interlobular spaces

and walls of the lactiferous ducts and ends into the sappeys plexus situated beneath the nipple and areola. Sappeys plexus also receives lymph from the nipple and the areola.
2. Some of the lymphatics run deeper along the ligaments of cooper to

drain into the lymphatic lake of Haller situated on the fascia covering the pectoralis major. From the lymphatic lake of Haller lymph vessels are drain into the following directions: a. From the upper part ends in the apical group of axillary lymph nodes. b. From the Lower and Lateral part ends in the pectoral group of lymph nodes to the Anterior abdominal parietes. c. From the Upper and Lateral part ends in pectoral group of the axillary lymph nodes. d. From the Lower and medial part ends in the sternal lymph nodes of the same side and some joining with the lymphatics of the opposite sides. Some drains into the mediastinal group of lymph nodes. e. From upper and medial part drains into the sternal lymph nodes of the same and opposite sides. f. From the lowest part of the medial area pass through the lymph plexus in the rectus sheath then pass along the falciform ligament to the hepatic lymph nodes. This is the dangerous area. II. FROM THE SKIN EXCEPT NIPPLE AND THE AREOLA. Lymphatics drain in the following ways:

a. From the upper marginal area. A) Apical group of Axillary lymph nodes. B) Infra clavicular lymph nodes. b. From the upper and lateral areas including axillary tail ends in the pectoral group of the Axillary lymph nodes. c. Lower and Lateral area ends in the A) Pectoral group of axillary lymph nodes. B) To the anterior abdominal parietes d. Medial area ends in the sternal group of lymph nodes at the same and opposite side runs along the internal mammary artery.

III. FROM THE STROMA SUPERFICIAL PART Along the lymphatics of the skin DEEP Along the lymphatics of the glandular tissue. Axillary lymph nodes receive more than 75% of the lymph from the mammary gland.

FIGURE: The Lymphatic drainage of the breast.

FIGURE: The Lymphatic drainage of the breast.

AXILLARY LYMPH NODES

DEFINATION: Axillary lymph nodes carry the lymph from the whole upper limb, the breast and from the body. (From the umbilicus to the clavicle) NUMBER OF LYMPH NODES: 20 TO 30 in number. DIVISION:

I. ANTERIOR OR PECTORAL GROUP

SITUATION Along the lower border of the pectoralis minor near the lateral thoracic vessels NUMBER 4 or 5 in number AFFERENTS (RECEIVE) 1. From the skin and muscle of supraumblical and Anterolateral part of the body wall. 2. From the lateral part of the breast. EFFERENTS (DRAIN) 1. Partly to the apical axillary nodes. 2. Partly to the central axillary nodes

II. POSTERIOR OR SUBSCAPULAR GROUP

SITUATION Inferior margin of the posterior Axillary wall, Along the subscapular vessels. NUMBER 6 or 7 in number AFFERENTS (RECEIVE) From the skin and muscles of the 1. Lower part of the back of the neck. 2. Dorsal aspect of the trunk down to the iliac crest. EFFERENTS (DRAIN) Apical and central axillary nodes.

III. LATERAL GROUP

SITUATION Posteromedially to the axillary vein NUMBER 4 to 6 in number AFFERENTS (RECEIVE) Whole upper limb except those going along the cephalic vein. EFFERENTS (DRAIN) 1. Partly to the central and apical axillary groups. 2. Partly to the lower deep cervical lymph nodes.

IV. CENTRAL GROUP

SITUATION It is embedded in Axillary fat. NUMBER 3 or 4 in number AFFERENTS (RECEIVE) From all preceding groups (Anterior, Posterior, Lateral) EFFERENTS (DRAIN) Drain to the apical nodes.

V. APICAL GROUP
SITUATION Deep to the clavipectoral fascia along the axillary vessels extending to the apex of the axilla. NUMBER 6 to 12 in number. AFFERENTS (RECEIVE) 1. Directly some of the lymph vessels accompany the cephalic vein. 2. From the mammary gland. 3. From the Anterior, Posterior, Lateral and central group of axillary lymph nodes. EFFERENTS (DRAIN) 1. Its afferents unite to form subclavian lymph trunk and drains into any of the followings

a. At the site of formation of Brachiocephalic vein.

b. Subclavian vein c. Jugular lymphatic trunk d. Right Lymphatic duct (Right side) e. Thoracic duct (Left side) 2. Few efferent usually ends in the inferior deep cervical nodes.

FIGURE: The lymph nodes of the axilla

INGUINAL LYMPH NODES

DEFINATION: The inguinal lymph nodes are situated immediately below the inguinal ligament. They mostly carry lymph from lower limb either directly or indirectly through the popliteal and anterior tibial nodes. CLASSIFICATION: Superficial Inguinal Lymph Nodes Deep Inguinal Lymph Nodes

I. SUPERFICIAL INGUINAL LYMPH NODES SITUATION Mostly over the fascia late. They are further divided into: 1. PROXIMAL OR HORIZONTAL SET: SITUATION Immediately below and parallel to the inguinal ligament. NUMBER 5 or 6 in number. These groups further consist of: A. LATERAL GROUP: AFFERENTS (RECEIVE): Buttock, Lateral part of Lower of Abdomen, Below the umbilicus. B. MEDIAL GROUP AFFERENTS (RECEIVE): a. b. c. d. e. f. Skin of the penis Scrotum Perineum Mucous membrane of the anterior part of the Urethra Anal canal Medial of the lower part of the Abdomen below the umbilicus g. Lymph vessels which accompanying the round ligament of uterus (female) h. Labia majora (Female) i. Lower part of the Vagina (Female) 2. DISTAL OR VERTICAL SET: SITUATION Along the upper end of the Great Saphenous vein. NUMBER 4 to 5 in number. AFFERENTS (RECEIVE)
a. Skin and fascia of the lower limb, except the buttock and the short

saphenous tributaries. b. Few lymphatics from the accompany the short saphenous vein. EFFERENTS (DRAIN) - All superficial inguinal lymph nodes drain into the external iliac group of lymph nodes some into the deep inguinal lymph nodes. II. DEEP INGUINAL LYMPH NODES SITUATION Beneath the fascia lata on the medial to the upper part of the femoral vein.

NUMBER 2 to 3 in number (most proximal mode of the group in femoral canal called CLOQUETS lymph node. AFFERENTS (RECEIVE) Superficial inguinal nodes. Popliteal nodes Glans penis (or) clitoris Deep lymphatics accompany the femoral vein EFFERENTS (DRAIN) External iliac group of lymph nodes.

FIGURE: The inguinal lymph nodes.