Assessment of lymphatic system

prepared for nursing students for easy understanding

1. Assessment O f Lymphatic System Arul Monisha

2. Overview of the Lymphatic System

3. The lymphatic system is a vital part of the  immune system, along with the thymus, bone marrow, spleen, tonsils, appendix, and Peyer patches in the small intestine. Like the  venous system, the lymphatic system transports fluids throughout the body. The lymphatic system consists of Thin-walled lymphatic vessels Lymph nodes Two collecting ducts

4. Lymphatic vessels,   located throughout the body, are larger than capillaries (the smallest blood vessels, which connect arteries and veins), and most are smaller than the smallest veins. Most of the lymphatic vessels have valves like those in veins to keep the lymph, which can clot, flowing in the one direction (toward the heart). Lymphatic vessels drain fluid called lymph from tissues throughout the body.

5. Lymph  begins as fluid that has diffused through the very thin walls of capillaries into the space between cells. Most of the fluid is reabsorbed into the capillaries and the rest is drained into the lymphatic vessels, which eventually return it to the veins. Lymph also contains many other substances including Proteins, minerals, nutrients, and other substances, which provide nourishment to tissues Damaged cells, cancer cells, and foreign particles (such as bacteria and viruses) that may have entered the tissue fluids

6. Lymph nodes  are collection centers for lymph. All lymph passes through strategically placed lymph nodes, which filter damaged cells, cancer cells, and foreign particles out of the lymph. Lymph nodes also contain specialized white blood cells (for example, lymphocytes   and  macrophages) designed to engulf and destroy damaged cells, cancer cells, infectious organisms, and foreign particles. Thus, important functions of the lymphatic system are to remove damaged cells from the body and to provide protection against the spread of infection and cancer.

7. The lymphatic vessels drain into  collecting ducts,  which empty their contents into the two subclavian veins, located under the collarbones. These veins join to form the superior vena cava, the large vein that drains blood from the upper body into the heart.

8. The Lymphatic System A circulatory system for fluids Returns fluid to the blood Removes antigens from the body Exposes antigens to the immune system Main structures of the lymphatic system Lymph Lymphatic vessels Lymph nodes Diffuse Lymphoid tissue, Eg: tonsils Lymphoid organs, Eg: spleen &Thymus Bone marrow

9. L y mph Lymph is a clear watery fluid, similar in composition to plasma , with important exception of plasma proteins and identical in composition to interstitial fluid. Transports the plasma proteins that seep out of the capillary beds back to the bloodstream. It also carries away larger particles, Eg. Bacteria, Cell debris etc. Contains lymphocytes which circulates in the lymphatic s y s t e m a llo w ing them to p a t r ol the di f f e r en t r eg io n s o f the body.

10. The Lymphatic System  Lymphatic vessels collect tissue fluid from loose connective tissue Carry fluid to great veins in the neck Fluid flows only toward the heart  Collect excess tissue fluid and blood proteins

11. Orders of Lymphatic Vessels Lymph capillaries Smallest lymph vessels  First to receive lymph Lymphatic collecting vessels Collect from lymph capillaries Lymph nodes Scattered along collecting vessels Lymph trunks Collect lymph from collecting vessels Lymph ducts Empty into veins of the neck

12. Lymphatic Capillaries Located near blood capillaries Receive tissue fluid from CT  Increased volume of tissue fluid  Minivalve flaps open and allow fluid to enter Highly permeability allows entrance of Tissue fluid Bacteria, viruses, and cancer cells Lacteals – specialized lymphatic capillaries Located in the villi of the small intestines Receive digested fats Fatty lymph – chyle

13. Location and Structure of Lymphatic Capillaries Figure 20.2a, b

14. Lymphatic Collecting Vessels Accompany blood vessels Composed of the same three tunics as blood vessels Contain more valves than veins do Helps direct the flow of blood Lymph propelled by Bulging of skeletal muscles Pulsing of nearby arteries Tunica media of the lymph vessels

15. Lymph Nodes Lymph nodes are bean shaped organs along with lymphatic collecting vessels Up to 1 inch in size Cleanse the lymph of pathogens Human body contains around 500 Lymph nodes are organized in clusters These nodes are considerably in size: some are as small as a pin head & the largest are about the size of an almond

16. Lymph Nodes

17. Microscopic Anatomy of a Lymph Node Outer Fibrous capsule – surrounds lymph nodes Trabeculae – connective tissue strands The main substance of the node consists of reticular and lymphatic tissue containing many lymphocytes and macrophages. Each node has a concave surface called hilum, where an artery enters & a vein and efferent vessel leaves. Lymph vessels Afferent lymphatic vessels Efferent lymphatic vessels

18. Microscopic Anatomy of a Lymph Node Functions: 1.Filtering and phagocytosis 2.Proliferation of lymphocytes.

19. Lymph Trunks Lymphatic collecting vessels converge Five major lymph trunks Lumbar trunks Receives lymph from lower limbs Intestinal trunk Receives chyle from digestive organs Bronchomediastinal trunks Collects lymph from thoracic viscera Subclavian trunks Receive lymph from upper limbs and thoracic wall Jugular trunks Drain lymph from the head and neck

20. Overview of the Lymph Nodes, Trunks, and Ducts

21. The Lymphatic Trunks

22. Lymph Ducts  Cisterna chyli  Located at the union of lumbar and intestinal trunks Thoracic duct Ascends along vertebral bodies Empties into venous circulation  Junction of left internal jugular and left subclavian veins Drains three quarters of the body Right lymphatic duct Empties into right internal jugular and subclavian veins

23. Spleen Largest lymphoid tissue; is in left hypochondriac region in between the fundus of stomach and the diaphragm. Purple in color, 12 cm long, 7cm wide and 2.5 cm thick and weighs about 200 g. Functions Removal of blood-borne antigens: “white pulp” Removal & destruction of aged or defective blood cells: “red pulp” Stores platelets In fetus: site of hematopoiesis

24. 18 Spleen

25. Lies in the upper part of the medistinum behind the sternum & extends upwards into the root of the neck. Weighs about 10-15 g at birth and grows until the individual reaches puberty. 30-40g by middle age . Prominent in newborns, almost disappears by old age Function: T lymphocyte maturation (immunocompetence) Has no follicles because no B cells Structure: Consists of two lobes joined by areolar tissue. Lobes are enclosed by a fibrous capsule which dips into their substances, dividing them into lobules that consist of an irregular branching framework of epithelial cells and lymphocytes. 19 Thymus

26. Palatine (usual tonsillitis) Lingual (tongue) (“a d e n oid s ”) Tubal T onsils * * Pharyngeal * Simplest lymphoid tissue: swellings of mucosa, form a circle Crypts get infected in childhood

27.  Aggregated lymphoid nodules (“Peyer’s Patches”) About 40 follicles, 1 cm wide Distal small intestine (ileum)  Appendix Parts of the intestine are so densely packed with MALT (mucosa-associated lymphoid tissue) that they are considered lymphoid organs

28. Lymph Node Assessment Palpate the regional lymph nodes of the head and neck, axillae, arms, and groin. Use firm, circular movements of the finger pads and note size, shape, symmetry, consistency, delineation, mobility, tenderness, sensation, and condition of overlying skin. Nodes should not be enlarged or painful Lymphadenopathy refers to the enlargement of lymph nodes (over 1 cm) with or without tenderness. It may be caused by inflammation, infection, or malignancy of the nodes or the regions drained by the nodes.

29. Lymph node enlargement with tenderness suggests inflammation (lymphadenitis). With bacterial infection, the nodes may be warm and matted with localized swelling . Malignant or metastatic nodes may be hard, indicating lymphoma; rubbery, indicating Hodgkin’s disease; or fixed to adjacent structures. Usually they are not tender. •Ear infections and scalp and facial lesions, such as acne, may cause enlargement of the preauricular and cervical nodes.

30. Anterior cervical nodes are enlarged and infected with streptococcal pharyngitis and mononucleosis . Lymphadenitis of the cervical and submandibular nodes occurs with herpes simplex lesions. Enlargement of supraclavicular nodes, especially the left, is highly suggestive of metastatic disease from abdominal and thoracic cancer . Axillary lymphadenopathy is associated with breast cancer. Lesions of the genitals may produce enlargement of the inguinal nodes.

31. Persistent generalized lymphadenopathy is associated with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex . Spleen Assessment: Palpate for the spleen, in the upper left quadrant of the abdomen. The spleen is normally not palpable . A palpable spleen in the left upper abdominal quadrant of an adult may indicate abnormal enlargement (splenomegaly) and may be associated with cancer, blood dyscrasias , and viral infection, such as mononucleosis

32. A dull percussion note in the lowest left ICS at the anterior axillary line or below the tenth rib at the midaxillary line suggests splenic enlargement Percuss for splenic dullness in the lowest left intercostal space (ICS) at the anterior axillary line or in the 9th to 10th ICS at the midaxillary line . Normally, tympany is heard.

33.  Lymphatic system    Introduction Mechanism and causes of lymphadenopathy Approach to lymphadenopathy: Hx, P/E, Lab  Splenomegaly    Introduction Causes of splenomegaly Evaluation of splenomegaly: Hx, P/E, Lab studies, Imaging...  Evaluation of swellings (Lumps)

34. it is responsible for the removal of interstitial fluid from tissues it absorbs and transports fatty acids and fats as chyle from the digestive system it transports white blood cells to and from the lymph nodes into the bones The lymph transports antigen-presenting cells (APCs), such as dendritic cells, to the lymph nodes where an immune response is stimulated

35.  Diagnostic dilemma Various causes with spectrum of clinical course Localized or Generalized Normal size of LNs  Larger in adolescents  Inguinal and submandibular  Recurrent trauma and infection

36.  Benign proliferation of residential cells  HIV Infection  Infiltration by inflammatory cells   Infection – lymphadenitis Auto-immune conditions- SLE  In situ proliferation of Malignant lymphocytes  L y mp h o m as

37.  Infiltration of lymph nodes by metastatic malignant cells    Breast cancer Colorectal cancer Lung cancer  Infiltration of lymph nodes by metabolite- laden macrophages:  Lipid storage diseases

38.  Infectious       Viral Bacterial Fungal C h l a m yd i a l Parasitic Rickettsial   Immunologic diseases Malignant diseases   He m a t o l o g ic Metastatic    Lipid storage diseases Endocrine diseases Other disorders

39.  Focused history    Sx of anemia Infection Bleeding  Duration of lymphadenopathy  Acute vs Chronic  Progression of the lymphadenopathy    Waxing & weaning Slow vs fast Involvement of adjacent or distant LN

40.  Associated symptoms    Pain Fever, hotness Sx of obstruction  Localizing symptoms of infections and malignancy   Draining sinus Hotness and local pain  Exposures    Radiation Chemotherapy Other agents: pets

41. Constitutional symptoms Travel history  Endemic areas  Medications associated with LAP   Anticonvulsants Drugs which cause LAP with serum sickness

42. Complete physical examination is vital Distribution    Localized Regional g e n e r a l i z e d  Symmetry

43.  Features characteristic of the lymph node      Location Size C o n s i ste n c y Fixation Tenderness Splenomegaly hepatomegaly

44. • C o mp o n e n t s – – – – – – Various laboratory and serologic tests Imaging Lymph node biopsy Bone Marrow study Other biopsies. ? Empirical treatment • Depend on various factors – – – – Age D u r a t i o n Localized/regional/generalized Epidemiology and the clinical setting

45.  Laboratory tests        CBC & Peripheral Smear ESR HIV R P R/ VDRL ANA Heterophile Antibody tests LDH & other tests according to the setting as well as importance

46.  Imaging study for the purpose of     Defining size & distribution more precisely Distinguishing from other similar structure Staging Guiding for FNA

47.  Imaging study includes       Chest X-Ray Ultrasonography & Doppler Nuclear/Isotope scans CT-Scan MRI P ET/ S P EC T

48. • Types of biopsy – – – Open biopsy Fine Needle Aspiration Core Needle Biopsy • Choice of LN & type of biopsy – – – – The most diseased Supraclavicular/cervical/axillary/inguinal If single go for open biopsy as much as possible accessability • Possible studies from the specimen – – – Pathological Immunochemistry/immunophenotype Genetic/molecular studies

49. EVALUATION OF SPLENOMEGALY

50.  Spleen is one of the lymphoid organs which is also called reticuloendothelial system.    Splenomegaly is common clinical condition & it is never normal Various causes with diagnostic challenge Other condition       Massive splenomegaly Splenic infarction Ruptured spleen Splenic abscess Functional hyposplenism/ asplenia Hypersplenism

51.  Lies in the Peritoneal cavity in the left upper quadrant. Adjacent to 9 th - 11 th rib, stomach, colon and pancreas. Weight    Male= 80-200g Female= 70-180g Average = 150g (0.2% of Body Weight)  Palpability and size   Not palpable normal ( children, adolescents, thin adults) Soft organ unless infiltrated

52. Participates in cellular and humoral immunity Removes senescent and/or poorly deformable red cells, bacteria, and other particulates from the circulation Under abnormal circumstances the spleen may become the site of extramedullary hematopoiesis Approximately one-third of circulating platelets are sequestered in the spleen, where they are in equilibrium with circulating platelets

53.  Splenic abnormalities can include      Increased function (hypersplenism) Decreased to absent function (hyposplenism, asplenia) Abscess, infarction, calcification, cysts Traumatic or atraumatic rupture Enlargement (Splenomegaly)

54. Splenic engorgement with sequestration Chronic inflammation or infection Lipid deposition Congenital condition Splenic infiltration

55.  1.Congestive    Cirrhosis Heart Failure Thrombosis of portal, hepatic and splenic veins  2.Malignancy      Lymphomas, usually indolent Leukemias Myeloproliferative Disorders Primary splenic tumours Metastatic solid tumours

56.  3. Infections      Viral - hepatitis, infectious mononucleosis, cytomegalovirus Bacterial - salmonella, brucella, tuberculosis Parasitic - malaria, schistosomiasis,toxoplasmosis, leishmaniasis Infective endocarditis Fungal

57.  4.Inflammation     Sarcoid Serum sickness Systemic lupus erythematosus Rheumatoid arthritis (Felty syndrome)  5.Infiltrative ( Non-Malignant)    Gaucher’s Glycogen storage disease Amyloidosis  6.Hematological ( Hypersplenic) states    Acute and chronic hemolytic anemias, all etiologies Sickle cell disease (children) Following use of recombinant human granulocyte colony-stimulating factor

58. Definition – splenomegaly >8cm BLCM Causes          Chronic myeloid leukemia Myelofibrosis, idiopathic or post-polycythemic Gaucher disease Lymphoma, usually indolent Hairy cell leukemia Kala-azar (visceral leishmaniasis) Hyperreactive malarial splenomegaly syndrome(tropical splenomegaly syndrome ) Thalassemia major AIDS with Mycobacterium avium complex

59. History Physical Examination Laboratory studies Imaging Additional studies  B i o psy

60.  Symptoms of splenomegaly    Pain, a sense of fullness, or discomfort in the left upper quadrant Pain referred to the left shoulder Early satiety, due to encroachment on the adjacent stomach Focused history Underlying conditions Constitutional symptoms Travel history

61. Complete physical examination Cardinal steps in spleen/ abdominal exam   In sp e c t i o n Palpation    Bimanual B a llo t t e m e n t Middleton’s method ( palpation from above)  Percussion    Nixon’s Method Castell’s Method Percussion of the Traube’s semilunar space  Auscultation

62.      CBC & Peripheral Smear ESR HIV R P R/ VDRL ANA, RF    Heterophile Antibody tests LDH & other tests according to the setting as well as importance

63.  Spleen      CT scanning magnetic resonance imaging ultrasound Tc-99m sulfur colloid scintigraphy 18F-FDG PET  Other sites   CXR CHEST CT

64.  Splenic Biopsy    Aspiration Following splenectomy Laparascopy Liver biopsy Bone Marrow Aspiration/Bone Marrow Biopsy Biopsy from other sites

65. • If there is an unusual lump anywhere in the body note the following – – – – – – – – Site /a p p ea r a n c e Size in diameter Shape & nature of surface skin Fixation Con s i st en c y Tenderness Pulsation & bruit(auscultation) Transillumination in a darkened room